^°H^rT^H'ts*Hi:i?^S' 


'HX64i  23707 
RC341  .P31  1904      a  practical  treatise 


intl)eCttpofJlm|ork 

CoUege  of  ^fjpsiiciang  anb  ^urgcong 

Hibrarp 


A    PRACTICAL  TREATISE  ON 

NERVOUS    DISEASES 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practicaltreatisOOpear 


< 


■       ^ 
r—       1J 


A   PRACTICAL  TREATISE  ON 

NERVOUS   DISEASES 

FOR    THE  MEDICAL  STUDENT  AND 
GENERAL  PRACTITIONER 


BY 

F.   SAVARY   PEARCE,   M.D. 

PROFESSOR   OF   NERVOUS    AND    MENTAL   DISEASES    IN   THE   MEDICO-CHIRURGICAL   COLLEGE 
OF  PHILADELPHIA;    FELLOW  OF  THE   COLLEGE  OF  PHYSICIANS   OF  PHILADELPHIA; 
NEUROLOGIST   TO  THE    PHILADELPHIA   AND    HOWARD    HOSPITALS;     MEM- 
BER   OF    THE   AMERICAN    MEDICO-PSYCHOLOGICAL   ASSOCIATION, 
AND  OF  THE  AMERICAN  CLIMATOLOGICAL  ASSOCIATION; 
CHAIRMAN  OF  SECTION  ON    NERVOUS  AND  MEN- 
TAL  DISEASES    OF  THE    AMERICAN 
MEDICAL   ASSOCIATION 


COLOURED  FRONTISPIECE 

NINETY-ONE  ILLUSTRATIONS  IN    THE    TEXT,    MANY 

IN  COLOURS 


NEW    YORK    AND    LONDON 

D.    APPLETON    AND    COMPANY 

19  04 


Copyright,  1904,  bt 
D.   APPLETON  AXD  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS 
NEW  TORK,   U.    S.   A. 


DEDICATED   TO 
S.   WEIR   MITCHELL,    M.D.,    LL.D. 

WHOSE  LIFE  HAS  BEEN  AN  INSPIRATION  FROM  CHILDHOOD 

AND  WHOSE  FRIENDSHIP  HAS  BEEN  OP 

VALUE  SINCE  EN  MEDICINE 


PREFACE 


This  text-book  on  Nervous  Diseases  has  been  written  for  the 
student  and  general  practitioner.  It  has  ever  been  the  object  to 
curtail  details  of  the  doubtful  points  in  neurology  and  to  make' 
most  in  small  compass  of  practical  facts  in  the  study  of  nervous 
disorders.  We  believe  that  this  is  the  surest  method  of  instilling 
knowledge  of  so  intricate  a  subject.  The  chapter  on  anatomy 
and  physiology  has  been  blended,  so  that  its  study  will  insure  a 
pretty  clear  understanding  of  the  anatomy  and  functions  of  the 
various  parts  of  the  nervous  system.  I  have  to  thank  my  col- 
league. Prof.  Isaac  Ott,  for  the  physiological  details  given.  I  beg 
to  acknowledge,  among  many  other  authorities,  special  reference 
to  the  works  of  Gowers,  Mills,  Dana,  Barker,  Osier,  and  Striim- 
pell,  to  the  latter  three  of  which  the  author  is  also  indebted  for 
several  cuts,  for  which  credit  is  given  in  the  text.  I  gratefully 
acknowledge  the  kindness  for  the  use  of  illustrations  from  The 
Diagnostics  of  Internal  Medicine,  by  Dr.  G.  E.  Butler,  and  Acci- 
dent and  Injury,  by  Dr.  Pearce  Bailey,  respectively;  also  to  Dr. 
M.  K.  Kassabian  and  Dr.  G.  E.  Pfahler  for  the  X-ray  produc- 
tions and  some  of  the  photographs. 

It  is  the  purpose  of  the  author  to  follow  this  contribution  by 
a  similar  treatise  on  Mental  Diseases,  so  that  the  two  works  can 
be  used  in  consonance  by  the  medical  student  and  busy  practi- 
tioner. 

F.  S.  P. 

1409  Locust  Street,  Philadelphia,  Pa, 


CONTENTS 


CHAPTER    I 

PAGE 

Section  I. — Anatomy  :   Classification  of  Nerves — Nerve  centres       .        1 

Nerve  cells — varieties 2 

Nerve  fibres — incisions  of  Lautermann 4 

Arrangement  of  nerve  fibres 5 

Nerve  centres  in  general .        5 

Differentiation  of  tracts  (three  methods) 9 

Names  of  tracts 11  to  13 

Degenerations      .        ." 13 

Tracts  of  descending  degeneration      .......  13  and  14 

"    ascending  "  14  and  15 

Medulla  oblongata 15  and  16 

Centres  in  medulla 17 

Pons  Varolii,  etc 17  and  18 

Cerebral  peduncles .18 

Capsules  of  brain 91 

Cerebellum .        .        .  19  and  20 

Cerebrum 20  and  21 

Optic  thalami 21  and  21 

Corpora  quadrigemini,  etc. 22 

Corpus  striatum 23 

Membi-anes  of  brain  and  cord 22 

Section  II. — Physiology  :  ^ 

Functions  of  spinal  cord 22,  23  and  24 

Pfluger's  laws 24 

Inhibition  of  reflexes ■ 24 

Brown-Sequard  on  reflex  activity       .       " 25 

Reflexes  of  spinal  cord 25  and  26 

Excitability  of  spinal  cord  . 26  and  27 

Paths  of  spinal  cord 27  and  28 

Nerve-fibres,  functions  of 28 

Irritability  and  stimuli  of  nerves        ....       29,  30,  31  and  32 
Transmission  of  nerve  impulses  >        .         .        .         .         .         .         .33 

Relay  stations  of  motor  and  sensory  fibres 33 

Chemical  and  mechanical  properties  of  nerve  substance   ...      33 
Physiology  of  the  cerebellum 33  and  34 


CONTENTS 


Section    II. — Physiology: 

Functions  of  medulla  .... 

"  "   pons  Varolii  .        .        , 

"  "  cerebral  peduncles 

"  "   corpora  quadrigemina  . 

"  "   corpora  striata 

"  "   optic  thalami 

The  capsules,  functions  of,  etc.    . 
Functions  of  cerebral  hemispheres 
Sleep  and  waking         .... 

H3-pnotics 

Strength  and  liminal  intensity  of  stimuli 
Weher-Fechnef  s  law    .... 
After  sensations   .... 
Functions  of  the  sympathetic  system 
Other  non-nervous  tissues  (blood-vessels,  neuroglia) 
Section  III. — Chemistry 


39 


34,  85  and  36 
.  36 
.      36 

36  and  37 

37  and  38 
.       38 

38  and  39 
40  and  41 
42  and  43 

.  43 
.  43 
45  and  46 
.  46 
.  46 
.  47 
47,  48  and  49 


CHAPTER    II 

General  pathology 50 

Sclerosis 50 

Degenerations .        .        .50  and  51 

Gliosis 51 

Inflammations  (varieties) 51,  52  and  53 


CHAPTER    III 

General  symptoms  and  methods  of  examination, 

diseases 

Guide  to  note-taking 

The  reflexes  recapitulated      .... 
Trophic,  vaso-motor  and  secretory  phenomena 
Examination  of  the  patient   .... 

Gait  and  station  (Romberg's  sign) 

Grasp — dynamometer  .... 

Pathologic  gaits 

Physiognomy 

Temperaments 

Decubitus     ..        =        ... 

Examination  for  sensation  (aBsthesiometer) 

"  "   motion 

Contraction  and  contracture    . 

Hemiplegia,  monoplegia,  paraplegia,  diplegia 

Ataxic  and  other  movements,  static  ataxia  . 

Table  of  tremors 


nomenclature  in  nervous 

54  and 


57,  58,  59 


60  and 

61  and 


56 
55 
61 
62 
.  62 
.  62 
.  63 
63  and  64 
.  64 
65 


64  and 

65  and 


67 
67 
67 
68 
68 


CONTENTS  xi 

PAGE 

Conjugate  deviation 69 

Pressure  sense 69 

Muscular  sense     .        .        .        .  ^ 69 

Weight  sense 69  and  70 

Sensations  of  motion 70 

Ocular  disturbances 70  and  71 

Colour  changes 71 

Pupillary  symptoms  (Argyll  Robertson  pupil)   .        .        .71,  72  and  73 

Hearing,  smell,  taste 73  and  74 

Reflexes  again  studied 74,  75,  76  and  77 

Surface  temperature 77 

"  "  in  erythromelalgia 77 

"        thermometer  (Mattson's) 77 


CHAPTER   IV 

General  therapeutics  and  prevention  of  nervous  disease,  and  the  acquire- 
ment of  nervous  health  ,         .        :         .         .        .         .         .         .         .77 

Hygiene        .        .        .  " 78,  79,  80  and  81 

Exercise 81  and  82 

Hydrotherapeutics  in  nervous  diseases 82  and  83 

Turkish  bathing 82  and  83 

Details  of  Turkish  bath 83  and  84 

Charcot  douche,  Scottish  douche 85 

Drip  sheet , 86 

Massage — five  sets  of  movements  in 86  and  87 

How  to  "  rub  "  a  patient 88  and  89 

Salient  points  of  massage 89  and  90 

Contra-indicatiqns  to  massage 90 

Muscular  movements 90 

Exercises  for  hands  and  feet 90  and  91 

"  "    body  and  lower  limbs 91  and  92 

Electricity 92 

Physics  of      .        .       ' .  92  and  93 

Physiology  of ,        .        .  92  and  93 

Diagnosis  and  prognosis  by 94 

Quantitative  change 94  and  95 

Qualitative  " 95 

Reaction  of  degeneration  and  examination  for  .  .  .95  and  96 
Generation  of  electricity  for  practical  therapy  ....  97 
Some  practical  indications  for  galvanism  .  .  .  .97  and  98 
Regulations  of  galvanic  current — axioms  ...  99  and  100 
Stabile — labile — nodal  point  and  sinusoidal  current  .        .        .     160 

Faradic  electricity  (induction  current) 101 

Uses  of  Faradic  electricity 102  and  103 

Franklin  or  static  electricity        ,        .        .        ,        .        .        .     105 


xii  CONTENTS 

PAGE 

Hypnotism 105  and  106 

"  Rest "  treatment  of  Weir  Mitchell    ....        107  and  108 

Object  of  the  "  rest "  treatment    .......     103 

Care  and  treatment  in  convalescence  from  functional  nervous' 

disease 108  and  109 

Physical  care,  adjunctsand  medication       .        .        110,  111  and  112 
Climatology  of  nervous  disease    =        .        .        .        ...        .     113 

CHAPTER   V 

Symptomatic  disorders 114 

Vertigo 114  and  115 

Insomnia '    .         .        116  and  117 

Neuralgia 118 

Facial  neuralgia 118 

Tic  douloureux 118  and  119 

Intercostal  jaeuralgia 119  and  120 

Sciatic  neuralgia 120 

Anterior  crural  neuralgia 120 

Visceral  neuralgia 121 

Neuralgia  of  heart  (angina) 121 

Headache 121 

"        causes  of 122 

"        megrim    .        . 132  and  123 

Meniere's  disease 124  and  125 


CHAPTER   VI 

Diseases  of  the  cranial  nerves 126 

Olfactory  nerve 126 

Optic  nerve  .        .        .        .        .     ■ 126  and  127 

Oculomotor  nerve 128 

Patheticus  (or  fourth  nerve) 129 

Trifacial  n. '.        .     129 

Abducens  n *     .       129  and  130 

Facial  n 130  and  131 

Auditory  n. 131  and  132 

Grlosso-pharyngeal  n 132 

Pneumogastric  n. 133 

Spinal  accessory  n 133  and  134 

Hypoglossal  n 135  and  136 

CHAPTER    VII 

Diseases  of  peripheral  nerves         ...,.,...    136 

Origin  of  nerves 136 

Pathology  of  nerves 137 

Neuritis ,        ,        .       137, 138  and  139 


CONTENTS  xiii 

PAGE 

Multiple  neuritis,  special  forms  of 140 

Recurrent  multiple  neuritis 144 

Leprous  neuritis 144  and  145 

Sciatic  neuritis 145,  146  and  147 

Tumours  of  nerves       .      ' 149,  150  and  151 

CHAPTER    VIII 

Diseases  of  other  spinal  nerves 152 

Cervical  plexus 152 

Long  or  posterior  thoracic  n 153  and  154 

Cervico-occipital  neuralgia 155 

Infrascapular  nerve 155 

Musculo-spiral  nerve 155,  156  and  157 

Ulnar  nerve 157  and  158 

Median  nerve 158  and  159 

Combined  palsies  of  nerves  of  arm 160  and  161 

Brachial  neuritis ■_    .        .        .        161  and  162 

Nerves  of  the  trunk 163 

"        "    "    lower  extremity 164 

Anterior  crural  n 164  and  165 

Obturator  n 165 

Superior  gluteal  n.    ,         .         .         .      " 165 

Great  sciatic  n. .        165  and  166 

Internal  popliteal  n. 166 

Metatarsalgia  {Morto7i's  disease) 166  and  167 

Rhizomelique  spondylitis 168  to  170 

CHAPTER   IX 

Diseases  of  membranes  of  brain     .        .        .        -. 171 

Pachymeningitis  externa 171 

Meningitis ...        171  and  172 

Acute  cerebral  pachymeningitis  ....        172,  173  and  174 

Cerebral  pachymeningitis  haemorrhagica  (or  haematoma  dura)  175  and  176 

Cerebral  leptomeningitis 177 

Hydrocephalus  (acute  and  chronic)    ....        177,  178  and  179 
Meningitis  serosa 182 

CHAPTER   X 

Diffuse  and  local  disease  of  brain 183 

Cerebral  localization  (epitomized) 183 

Occipital  lobe    .._...        =        .        o        ..        .  183 

Temporal  lobe 184  and  185 

Prefrontal  region 186 

Centrum  ovale 186 

Corpus  callosum .        .        •  186 

"        striatum       ...,,,,,.,  186 


XIV 


CONTENTS 


PAGE 

Optic  thalamus 186 

Internal  capsule 187 

Crus  cerebri .  188 

Pons  or  bulb 188 

Cerebellum 188 

Medulla  oblongata 188 

Aphasia  (varieties) 189, 190  to  194 


CHAPTER    XI 


Other  diseases  of  brain  and  membranes 
General  symptomatology 
Malformations  of  brain  and  membranes 

Meningocele 

Apoplexy  (cerebral  hfemorrhage) 

"  diagnosis  .... 
"  prognosis  .... 
"         treatment  and  nursing 

Encephalitis 

Brain  tumour  (cerebral  neoplasm) 
"      symptoms  and  localization 
"      pathology,  diagnosis,  prognosis  and  treatment 


198, 


.    195 
.    195 

196  and  197 

197  and  198 
199,  200  and  204 

.'    205 

.    205 

205  and  206 

307  and  208 

209  and  210 

210  and  211 

211  and  212 


CHAPTER   XII 

Inflammations  of  membranes  of  cord  and  unclassified  diseases  .        .        .     213 

Inflammations  of  spinal  dura  (pachymeningitis)        .        213,  214  and  215 

"  "       "      pia  (leptomeningitis)    .        .        .        215  and  216 

Caisson  disease  (divers'  disease) 217  and  218 

Landry's  disease  (acute  ascending  paralysis)      .        .        .       219  and  220 


CHAPTER   XIII 

Diseases  of  the  spinal  cord 221 

General  considerations 221 

Special  diseases 222 

Malformations  :  Heteropia,  meningocele,  amyelia,  double  cord,  split- 
ting of  cord,  agenesis,  micromyelia      .        .        223,  224,  225  and  226 

System  diseases  (sensory  and  motor  neurons)     .        .        .        =        .     226 
Locomotor  ataxia  (tabes) ;  (symptoms,  diagnosis,  prognosis  and 

treatment)  .        .       " 226,  227  to  233 

Primary  lateral  sclerosis 234  to  236 

Spastic  spinal  paralysis 236  to  238 

Hereditary  spastic  spinal  paralysis 238 

Friedreich's  disease  (hereditary  ataxia)  ....       238  and  239 
Cerebellar  ataxia 240 

Functional  disorders  of  spinal  cord    .        , 240 

Cauda  equina — diseases  of 241  and  242 


CONTENTS  XV 

CHAPTER   XIV 

PAGE 

Diffuse  and  local  disease  of  spinal  cord         .        .        .        .        .        ,        .     243 

Spinal  anaemia ;  spinal  haemorrhage  (spinal  apoplexy)       .        .        .    244 

(1)  Haematorrhachis  ;  (2)  hasmatomyelia.        ....  244  to  247 

Syringomyelia 247,  248  and  249 

Muscular  dystrophies  (varieties)  .        ,        =        .        .  250  to  252 

(1)  Pseudohypertrophic  paralysis    .        .        ,        .        250,  251  and  252 

(2)  Idiopathic  muscular  atrophy 252 

(a)  (Pacio-scapulo-humeral) 252 

(b)  (Juvenile  form  of  Erb) 254 

(3)  Neuritic  type 254  and  255 

Anterior  poliomyelitis  acuta  (infantile  palsy)    .        .        255,  256  and  257 
Glosso-labio-phai'yngeal  palsy  (bulbar  palsy) ;  (1)  acute ;  (2)  chronic  ; 

(3)  asthenic  ;  (4)  pseudo 257  and  258 

Combined  scleroses 260 

(1)  Hereditary  ataxia  (see  p.  238) 260 

(2)  Type  of  Putnam-Lichthein-Dana      .        .      •  .        .        .  260  to  262 
Myelitis  :  Causes,  types,  symptoms,  prognosis,  pathology  and  treat- 
ment     .        .        . 262,  263,  264  to  266 

CHAPTER   XV 

Diffuse  diseases  of  brain  and  cord 267 

Multiple  or  insular  sclerosis :  Symptoms,  diagnosis,  prognosis  and 

treatment 267, 268  and  269 

Paralysis  agitans  (Parkinson's  disease)       . .       .        269,  270,  271  and  272 

Nervous  syphilis 272 

General  considerations 272 

Pathology 273  and  274' 

Diagnosis 275 

Pi'ognosis 275 

Treatment 275  and  276 

CHAPTER    XVI 

General  and  functional  nervous  diseases 277 

Classification 277 

Chorea  minor  (St.   Vitus's  dance) :    Types,  symptoms,   diagnosis, 

prognosis  and  treatment 278  to  282 

Habit  chorea  (habit  spasm) 283  and  284 

Hereditary  chorea  {Huntingdon's  disease)         .        .        284,  285  and  286 
Convulsive  tic  {Giles  de  la  Totirette's  disease)    .        .        .        286  and  287 

Saltatory  spasm  (jumpers'  disease) 287  and  288 

Myotonia  congenita  (Thomsen's  disease)     ....        288  and  289 

Epilepsy 289  and  290 

Definition,     aetiology,    symptomatology,    pathology,     diagnosis, 

prognosis  and  treatment 289  to  295 

Neurasthenia  (nervous  exhaustion) 295 


xvi  COJS' TENTS 

PAGE 

Symptoms,  astiology.,  pathology,  diagnosis,  prognosis  and  treat- 
ment . 295  to  302 

-Hysteria 302 

Symptoms,  aetiology,  pathology,  diagnosis,  prognosis  and  treat- 
ment   302  to  308 

Traumatic  hysteria  (railway  spinej 308 

Symptoms,  aetiology,  diagnosis,  prognosis  and  treatment       .  309  to  312 

Saltatory  spasm 312 

Salaam  convulsions 312 

Writer's  cramp  (artisan's  jaalsy) :  Symptoms,  types,  prognosis,  treat- 
ment   313  and  314 

CHAPTER   XVII 

Vasomotor  and  trophic  disorders 316 

Exophthalmic   goitre   (Graves'  disease) :  Causes,  symptoms,   prog- 
nosis and  treatment 316  to  319 

Glass-blowers'  disease 319 

Sudden  changes  in  the  hair 320  and  321 

Hyperostosis  cranii  (cephalomegaly) 333  and  324 

Adiposis  dolorosa 324  and  325 

Facial  hemiatrophy 326 

"       hemihypertrophy 326 

Dermatitis  gangrenosa  nervosa 327  and  328 

Mysoedema  and  cretinism  .        .        .        .        .        .        .       328  and  329 

Scleroderma         . 329  and  330 

Ainhura 330 

Acromegaly  ..........  331  to  333 

Hypertrophic  pulmonary  osteo-arthropathy      .        .        .        333  and  334 

Arthritis  deformans  (rheumatoid  arthritis) 334  to  340 

Heat  exhaustion 340  and  341 

Sunstroke  (insolation) ~.        .       341  and  342 

Myasthenia  gravis 342  and  343 

Family  periodic  paralysis 343  and  344 

CHAPTER   XVIII 

General  toxsemic  diseases  of  the  nervous  system 845 

Hydrophobia  (rabies)   ........       345  and  346 

Tetanus  (lockjaw) 347,  348  and  350 

■  Tetany  (tetanilla) ,        .       350, 351  and  353 

.   CHAPTER   XIX 

Drug  intoxications 354 

Alcoholism  (alcoholic  insanity)    .        .        .        .        .       354, 355  and  356 

Tobacco  poisoning 356  and  357 

Tea  and  coffee  poisoning. 357 


CONTENTS  xvii 

PAGE 

Lead,  mercuiy,  and  arsenic  poisoning        ....  357  and  358 

Opium  poisoning 358  and  359 

Cocaine  liabit 359  and  360 

Coal-tar-products  intoxication 360  and  361 

CHAPTER    XX 

General  paresis  (paresis) :  Types :  symptoms,  aetiology,  pathology,  diag- 
nosis, prognosis  and  treatment 362  to  366 

Syphilitic  pseudo-paresis 366 

Alcoholic  pseudo-paresis 366 

Treatment  of  all  forms 368 


APPENDIX 

Disorders  of  sleep 369 

(a)  Wakeful  disorders 370  and  371 

(h)  Somnolent     "  372  and  373 

Additional  figures 373  to  384 

Tables 385  and  386 

Formulary 387  to  390 


LIST  OF  ILLUSTRATIONS 


FIG.  PAGE 

Ervthromelalgia  of  right  foot  Frontispiece 

1.  The  neurone  (diagrammatic) .         .         .  3 

2.  Functions  of  the  fibres  of  the  anterior  and  posterior  roots,  etc.     .        .  6 

3.  The  parts  and  columns  of  the  spinal  cord,  and  some  of  the  diseases 

which  affect  them 6 

4.  Tracts  of  the  spinal  cord  and  their  varied  nomenclature       ...  8 

5.  Functions  of  the  various  tracts  of  the  spinal  cord 10 

6.  The  relation  of  the  segments  of  the  spinal  cord,  etc.,  to  the  spinous 

processes  of  the  vertebrae   .        .        . 12 

7.  Sensory  pathways 44 

8.  Motor  pathways 45 

9.  The  relation  of  the  spinal  cord  to  the  dorsal  surface  of  the  trunk,  etc.  47 

10.  Position  of  hand  in  local  tonic  hysterical  spasm 56 

11.  Krauss's  plessimeter 57 

12.  The  Jendrassik  method  of  obtaining  the  knee-jerk        ....  58 

13.  Taylor  knee-jerk  hammer 59 

14.  Showing  the  method  of  obtaining  the  triceps  and  supinator  jerk.         .  60 

15.  Weir  Mitchell's  apparatus  for  clinical  observations  of  station      .        .  62 

16.  Dynamometer 62 

17.  Hand-dynamometer 63 

18.  Carroll's  ^sthesiometer 66 

19.  Diagram  of  visual  paths 73 

20.  Mechanism  of  deep  reflexes ;  also  the  two  main  types  (spastic  and  flac- 

cid) of  paralysis 75 

21.  Complete  galvanic  dry-cell  battery 100 

22.  Combination  dry-cell  galvanic  and  faradic  battery        ....  101 

23.  Complete  electric  cabinet .        .        .  102 

24.  Static  machine  and  complete  series  of  electrodes 104 

25.  Congenital  nystagmus 128 

26.  Facial  palsy,  left  side 130 

27.  Attitude  in  spasmodic  torticollis 184 

28.  Supranuclear  palsy  of  the  right  hypoglossal  nei've         ....  135 

29.  Bedridden  case  of  multiple  neuritis 141 

30.  Wrist  drop  from  musculo-spiral  alcoholic  pressure  palsy       .         .        .  157 

31.  Distribution  of  the  sensory  nerves  of  the  skin  of  the  arm,  anterior 

aspect 159 

33.  Distribution  of  the  sensory  nerves  of  the  skin  of  the  arm,  posterior 

aspect          . 159 

xix 


XX  LIST    OF    ILLUSTEATIOXS 


33.  Distribution  of  the  sensory  nerves  of  the  skin  of  the  leg,  posterior 

aspect  

34.  Distribution  of  the  sensory  nerves  of  the  skin  of  the  trunk  and  leg, 

anterior  aspect 

35.  Distribution  of  the  sensory  nerves  of  the  skin  of  the  trunk,  posterior 

aspect  

36.  Distribution  of  the  sensory  nerves  of  the  skin  of  the  foot 

37.  Ehizomelique  spondylitis 

38.  Haemorrhagie  pachymeningitis  interna  (alcoholic) 

39.  Brain  ;  case  of  hydrocephalus  in  a  child  of  five  years     . 

40.  Spastic  diplegia  from  chronic  hydrocephalus  (adult  male)    . 

41.  Schematic  reiDresentation  of  the  cerebral  cortex  and  its  centres    . 

42.  View  of  the  right  cerebral  hemisphere  from  the  median  side 

43.  Diagram  of  motor  and  sensory  representation  in  the  internal  capsule 

44.  Zones  and  centres.     External  aspect.     Cerebrum  .... 
4*5.  Zones  and  centres.     Mesal  aspect.     Cerebrum        .... 

46.  Fleehsig"s  association  areas,  lateral  aspect     .  *     . 

47.  "  *■  "      mesal  aspect 

48.  Lack  of  development.     Left  half  of  cerebrum        .... 

49.  Arteries  at  the  base  of  the  brain 

50.  The  portions  of  the  cerebral  hemisphere  supplied  by  the  anterior 

middle  and  posterior  cerebral  arteries 

51.  Area  of  thrombosis  and  haemorrhage  motor  area  cerebrum.     X-ray 

photograph 

52.  Hyperpyrexia  in  cerebral  haemorrhage  ;  male,  aged  sixty-one  years 

53.  Chronic  cervical  tubercular  external  pachymeningitis  . 

54.  Atrophy  of  interossei,  thenar  and  hypothenar  muscles  of  both  hands 

55.  Agenesis  and  micromyelia  of  spinal  cord  in  a  male  aged  forty  years 
•  56.  Standing  posture,  static  ataxia  in  tabes  dorsalis    .... 

57.  Charcot  joints  in  tabes 

58.  Tumour  (psaramoma)  springing  from  dura,  lower  dorsal  cord 

59.  Atrophy  of  intrinsic  muscles  of  the  hand  with  thermo-aneesthesia 

60.  Pseudohypertrophic  paralysis  showing  atrophy  of  shoulders,  girdle 

and  thighs 

61.  Progressive  muscular  atrophy  of  spinal  origin 

62.  Combined  sclerosis  of  the  type  Putnara-Lichthein-Dana,  followed  by 

left  hemiparesis 

63.  Expression  "  pill-rolling"  hands  and  attitude  in  paralysis  agitans 

64.  Communications  of  the  nervous  system  to  the  genital  organs 

65.  Hysterical  paralysis;   braces  and  wheel-crutch  applied   to   assist  in 

walking 

66.  Exophthalmic  goitre.     Prominent  eyes  and  thyreoid  gland 

67.  Trophoneurosis  of  the  hair,  showing  change  from  dark  to  white 

68.  Universal  alopecia  of  nervous  origin       .... 

69.  Hyperostosis  cranii 

70.  Skull-cap  from  same  case  of  hyperostosis  cranii     . 

71.  Adiposis  dolorosa  in  a  colored  woman     .... 

72.  Dermatitis  gangrenosa  nervosa,  showing  scars  on  left  hand 


159 

162 

164 
167 
169 
176 
180 
181 
184 
185 
187 
190 
192 
193 
194 
197 
199 

200 

201 
203 

214 
216 
225 
•  228 
230 
241 
248 

251 
253 

2G1 
269 
296 

306 
316 
320 
321 
322 
323 
325 
327 


LIST    OF    ILLUSTEATIONS  xxi 

FIG.  PAGE 

73.  Sporadic  cretinism 328 

74.  Acromegaly  in  a  woman,  showing  enlarged  supra-orbital  ridges,  infe- 

rior maxilla  and  hands 332 

75.  Agglutination  of  patella  to  tibia  and  subluxation  of  knee  in  rheuma- 

toid arthritis  ;  X-ray  photograph 335 

76.  Erosion  joints  of  hands,     Rlieumatoid  arthritis.     X-ray  photograph   .  33G 

77.  Hheumatoid  arthritis  with  contractures 338 

78.  Rheumatoid  arthritis,  after  operation  and  braces  are  applied       .        .  339 

79.  Paretic  dementia,  ordinary  type,  second  stage 363 

80.  Spastic  and  athetoid  movements  in  face,  tongue,  and  pharyngeal  muscles  373 

81.  Attitude  in  a  case  of  general  athetosis  in  cerebral  palsy  of  childhood  374 
83.  Secondary  contractions  of  face,  arm,  hand,  foot,  and  leg  in  case  of 

chronic  left  hemiplegia 375 

83.  Tumour  (endotheliouia),  inner  surface  cerebral  dura      ....  376 

84.  Horizontal  linear  light  shadow  (radiograph),  showing  result  of  specific 

meningitis  and  erosion  of  inner  plate  of  parieto-frontal  bones        .  377 

85.  Showing  motor  points  (head  and  neck) 378 

86.  Showing  motor  points  (shoulder  and  arm)  anterior  aspect    .        .        .  379 

87.  "             "           "              "           "       "      posterior    "...  380 

88.  "  "  "      (leg) .        .381 

89.  Showing  the  effects  of  various  lesions  of  the  motor  path  in  the  brain 

and  spinal  cord 382 

90.  Diagram  of  skin  areas  corresponding  to  the  different  spinal  segments 

(anterior  aspect) 383 

91.  Diagram  of  skin  areas  corresponding  to  the  different  spinal  segments 

(posterior  aspect) 384 


A   PRACTICAL   TREATISE   ON   NERVOUS 
DISEASES 


CHAPTEE    I 

GENERAL  ANATOMY,   PHYSIOLOGY,   AND   CHEMISTRY  OF 
THE  NERVOUS  SYSTEM 

Section"  I. — Anatomy 

The  structure  of  the  nervous  system  may  be  distinctly  divided 
into  five  parts,  as  follows : 

1.  ISTon-medullated  nerve-fibres. 

2.  Mednllated  nerve-fibres. 

3.  Neuroglia. 

4.  Supporting  connective-tissue  framework^  besides  the  neu- 
roglia. 

5.  Nerve-cells. 

Classification  of  Nerves. — Nerve-fibres  may  be  classified  into 
three  main  groups,  according  to  the  direction  in  which  they  con- 
vey normally  nervous  impulses.     These  three  divisions  are: 

1.  Efferent  nerve-fibres. 

2.  Afferent  nerve-fibres. 

3.  Intercentral  nerve-fibres. 

Ejferent  or  centrifugal  nerves  are  those  which  conduct  nerv- 
ous impulses  from  the  central  nervous  system  (brain  and  spinal 
cord)  to  other  parts  of  the  body. 

Afferent  or  centripetal  nerves  are  those  which  conduct  nervous 
impulses  in  the  opposite  direction — namely,  from  all  parts  of 
the  body  to  the  central  nervous  system. 

Intercentral  nerves  are  those  nerves  which  connect  nerve-cen- 
tres together;  they  connect  different  parts  of  the  brain  and  of 
the  cord  to  one  another. 

Nerve-Centres. — Nerve-centres  are  composed  of  white  and  gray 
matter.  In  the  brain  the  gray  matter  is  on  the  outside,  and  in 
1  1 


2  TEEATISE    ON    NEEYOUS    DISEASES 

the  spinal  cord  it  is  on  the  inside.  The  white  matter  is  made  up 
of  nerverfibres,  and  the  gray  matter  of  cells  and  an  interposing 
cement  substance  called  neuroglia.  It  is  expedient  to  here  explain 
Avhat  is  meant  by  the  neuroglia.  This  is  the  cementing  tissue  ol 
the  nervous  system,  of  ectod.ermic  origin — differing  from  connect- 
ive tissue,  which  is  solely  derived  from  the  mesoderm — and  in  the 
spinal  cord  it  arises  in  part  from  the  pia  mater  and  passes  into 
the  white  matter,  carrying  with  it  blood-vessels,  and  forming  ssepta 
which  separate  the  nerve-fibres  into  bundles.  Neuroglia  proper 
is  made  up  of  a  delicate  reticulum,  holding  in  its  meshes  the 
small  glia  cells. 

Nerve-Cells. — Nerve-cells  differ  greatly  in  size  and  shape. 
The  nucleus  is  generally  large  and  spherical,  containing  a  dis- 
tinct nucleolus.  They  may  be  roughly  divided  into  three  groups, 
according  to  the  number  of  protoplastic  processes  they  possess, 
into  imijwlar,  bipolar^  and  multipolar  cells. 

Unipolar  cells  are  found  in  the  spinal  ganglia.  They  are 
spherical  in  shape,  are  inclosed  in  a  nucleated  sheath,  and  the 
single  process  after  a  short  course  joins  one  of  the  nerve-fibres 
traversing  the  ganglion  by  a  T-shaped  junction. 

Bipolar  cells  are  cells  with  two  branches  or  processes.  The 
embryonic  condition  of  the  cells  of  a  spinal  ganglion  is  one  ex- 
ample of  these. 

Multipolar  Cells. — Here  the  cell  becomes  angular  or  stellate. 
It  was  formerly  thought,  in  some  instances,  as  in  the  cells  of  the 
sympathetic  ganglia,  that  all  the  processes  become  nerve-fibres, 
but  this  is  not  so,  for  here,  as  well  as  in  the  large  cells  of  the  gray 
matter  of  the  spinal  cord,  only  one  process  becomes  the  axis  cylin- 
der of  a  nerve-fibre,  the  others  dividing  and  subdividing  in  a 
ramified  manner  until  they  end  in  an  arborescence  of  fine  twigs. 

The  nerve-cell  is  the  fundamental  characteristic  unit  of  the 
gray  matter,  and  is  known  as  a  neuron  (Waldeyer,  1891).  Some 
of  these  cells  are  coloured  or  pigmented,  such  as  in  the  locus  niger, 
where  they  are  black;  nucleus  ruber,  where  they  are  red,  as  its 
name  would  imply,  etc.  Every  nerve-cell  has  an  axis-cylinder  proc- 
ess, which  has  been  variously  called  the  axis  cylinder,  neurit,  ax- 
one,  or  neuraxon.  The  protoplasmic  prolongations  of  the  nerve- 
cells  are  called  dendrons.  According  to  the  number  of  these  proc- 
esses, the  nerve-cells  are  termed,  as  before  stated,  unipolar,  bipolar, 
and  multipolar. 


DENDRITES' 


N 
E 
U 
R 
0 
N 


B 


^ 


Carry  impulses  to  the  cell 
Degenerate  if  separated  from  It 


Is  the  container  and  generator  of 

nerve  force 
Is  trophic  for  dendrites  and  axones 


Carries  impulses  from  the  cell  body 
Degenerates  if  separated  from  it 


A  "  Upper  or  cerebral  motor 

NEURONE 

Exercises  an  inhibitory  con- 
trol OVER  B 


(  Intermingles  but  does  not  unite  with 
■<  dendrites  of  neurone,  to  which  it 
(     carries  impulses 


6  =  Lower  OR  peripheral  mo- 
tor NEURONE 

Exercises  trophic  influence 

OVER  AND    maintains  TONUS 

of  muscles 


End  organ 

In  muscular  fibre 


Fig.  1. — The  neurone  (diagrammatic).     (From  Butler's  Diagnostics  of  Internal  Medi- 
cine, 1902.) 


4  TREATISE    OX   XERVOUS    DISEASES 

The  nerve-cells  vary  from  ^o¥  ^°  j¥o  of  an  inch  in  diameter. 
The  lai'gest  nerve-cells  are  found  in  the  anterior  horns  of  the 
spinal  cord  and  in  the  vicinity  of  the  fissure  of  Rolando. 

Nerve-Fibres. — The  nervous  system  is  composed  of  two  parts — 
the  central  nervous  system  and  the  peripheral  nervous  system. 
The  central  nervous  system  consists  of  the  brain  and  the  spinal 
cord:  the  peripheral  nervous  system  consists  of  the  nerves  which 
conduct  the  nervous  impulses  to  and  'from  the  central  nervous 
system^  and  thus  bring  the  nerve-centres  in  relation  with  other 
parts  of  the  hody. 

Xerve-fibres  are  of  two  histological  kinds,  viz.,  medullated  and 
non-medullated.  Medullated  nerve-fibres  are  found  in  the  white 
matter  of  the  nerve-centres  and  in  the  nerves  originating  from 
the  brain  and  spinal  cord.  Xon-medullated  nerve-fibres  occur  in 
the  sympathetic  system. 

The  medullated  or  vjlvite  fibres  are  characterized  by  the  sheath 
of  white  colour,  fatty  in  nature,  and  stained  black  with  osmic 
acid;  it  is  called  the  medullary  sheath  or  white  substance  of 
Schwann;  this  ensheaths  the  essential  part  of  the  fibre,  which  is 
a  process  from  a  nerve-cell,  and  is  called  the  axis  cylinder.  Ac- 
cording to  Piersol,  the  axis  cylinder  is  covered  by  a  thin,  trans- 
parent, elastic  sheath,  called  the  axilemma.  The  substance  of 
Schwann  is  ensheathed  by  a  thin,  homogeneous  membrane  of  an 
elastic  nature,  called  the  neurilemma. 

The  axis  cylinder  is  made  up  of  a  number  of  small  fibrils,  which 
are  held  together  by  a  cement  substance  called  the  neuroplasm. 

Along  the  course  of  a  medullated  nerve-fibre  there  are  numer- 
ous constrictions  called  the  annular  constrictions  or  nodes  of  Ran- 
vier.  At  these  constrictions  the  neurilemma  lies  in  direct  conta-ct 
with  the  axis  cylinder  of  said  nerve.  According  to  some  author- 
ities, the  axilemma  lies  interposed.  The  stretch  of  nerve  between 
two  nodes  is  called  an  internode,  and  in  the  middle  of  each  node 
is  a  nucleus  which  belongs  to  the  primitive  sheath.  The  nucleus 
is  not  necessarily  always  in  the  middle,  for  in  some  cases  it  is 
found  to  be  variously  distributed. 

Incisures  of  Lantermann. — In  each  interannual  segment  in  a 
nerve  that  is  stretched  there  will  be  noticed  a  number  of  oblique 
lines  running  across  the  white  substance  of  Schwann.  This  indi- 
cates that  the  segments  of  Schmidt  are  built  up  of  a  series  of 
conical  sections,  each  of  which  is  bevelled  at  its  ends,  while  the 


AXATOMY,    PHYSIOLOGY,    AXD    CHEMISTRY        5 

sHglit  interval  between  them  appears  as  an  incisure  of  Lanter- 
mann. 

The  iibres  of  the  nerve-centres  differ  from  the  preceding  in 
that  they  have  no  neurilemma  and  no  annular  constrictions.  When 
a  nerve  enters  the  spinal  cord  or  brain  it  loses  its  neurilemma. 

The  non-meduHated  fibres  or  filjres  of  Remak  have  no  medul- 
lary sheath,  and  are  therefore  devoid  of  the  double  contour  of  the 
medullated  fibres,  and  are  unaffected  in  appearance  by  osmic  acid. 
They  consist  of  an  axis  cylinder  covered  by  a  nucleated  fibrillated 
sheath.  These  nerves  branch  very  frequently.  They  are  princi- 
pally found  in  the  sympathetic  system,  a  few  being  found  in  the 
spinal  nerves  mixed  with  the  medullated  fibres. 

Arrangement  of  Nerve-Fibres. — The  arrangement  of  nerve- 
fibres  is  best  seen  in  transverse  section. 

The  nerve  is  composed  of  a  number  of  bundles  of  funiculi  of 
nerve-fibres  bound  together  by  connective  tissue.  The  sheath  of 
the  whole  nerve  is  called  the  epineurium  :  that  of  the  funiculi  the 
perineurium;  that  which  passes  between  the  fibres  in  a  funiculus 
the  endoneuriurn. 

The  size  of  a  nerve-fibre  is  from  -g-oVo"  "to  ti'Vo'  ^f  an  inch  in 
.diameter. 

Nerve-Centres  in  General. — The  nerve-centres  in  general  are 
the  spinal  cord,  medulla  ohlongata,  pons  varolii,  cerebellum,  and 
cerebrum. 

Spinal  Cord. — The  spinal  cord  is  enclosed  in  the  bony  canal 
formed  by  the  spinal  vertebrae;  it  extends  from  the  margin  of  the 
foramen  magnum  to  the  lower  border  of  the  first  lumbar  vertebra, 
terminating  in  a  slender  filament  of  gray  substance,  the  filum 
terminale,  which  lies  in  the  midst  of  the  roots  of  many  nerves 
forming  the  cauda  equina.  It  does  not  fill  the  canal  altogether, 
but  is  suspended  in  the  cerebro-spinal  fluid.  It  has  two  enlarge- 
ments, one  in  the  cervical,  the  other  in  the  lumbar  region.  These 
are  the  situations  whence  the  large  nerves  for  the  supply  of  the 
limbs  issue.  The  spinal  cord  is  from  15  to  18  inches  in  length 
and  weighs  about  one  ounce. 

It  is  composed  of  white  and  gray  matter;  the  white  matter 
is  situated  externally,  and  constitutes  its  chief  portion;  the  gray 
matter  is  in  the  interior,  being  so  arranged  that  in  a  transverse 
section  of  the  cord  it  appears  like  two  crescentic  masses  which 
are  connected  together  by  a  narrower  portion  which  is  known  as 


PAIN  AND  TEM- 
PERATURE  SENSE, 


TACTILE 
SENSE 


REFLEX  AND 
VISCERAL 


Fig.  3. — Showing  the  functions  of  the  fibres  of  the  anterior  and  posterior  roots,  and 
their  relations  to  the  horns  and  columns  of  the  spinal  cord.  (Redrawn  and  modi- 
fied from  Dana.) 


Fig.  3. — Showing  the  parts  and  columns  of  the  spinal  cord  and  some  of  the  diseases 
which  aflfect  them.     (From  Butler.) 

a 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY         7 

the  posterior  commissure.  In  the  centre  of  this  narrow  portion 
is  located  the  central  canal.  Directly  in  front  of  the  posterior 
commissure  is  located  the  anterior  commissure,  which  is  composed 
of  white  matter. 

The  spinal  cord  consists  of  two  lateral  halves,  separated  an- 
teriorly by  the  anterior  median  fissure,  which  extends  from  the 
front  surface  of  the  spinal  cord  to  the  anterior  or  white  commis- 
sure. Posteriorly  it  is  separated  indistinctly  by  the  posterior  me- 
dian fissure,  which  extends  from  the  posterior  surface  of  the  spinal 
cord  to  the  posterior  or  gray  commissure.  The  posterior  fissure 
is  deeper  than  the  anterior,  but  it  is  not  as  wide  nor  is  it  so  dis- 
tinct. The  posterior  fissure  extends  from  the  calamus  scriptorius 
in  the  fourth  ventricle  above  to  the  termination  of  the  cord  below. 

On  the  lateral  surface  of  the  cord  are  noticed  two  longitudinal 
furrows,  which  divide  each  half  of  the  cord  into  three  columns, 
viz.,  anterior,  lateral,  and  posterior.  From  the  furrow  between 
the  anterior  and  lateral  columns  spring  the  anterior  (motor) 
nerves;  from  the  furrow  between  the  lateral  and  posterior  col- 
umns spring  the  posterior  (sensory)  nerves. 

The  cord  is  composed  of  a  cortical  white  substance  and  a  cen- 
tral gray  matter.  The  white  matter  is  made  up  of  medullated 
nerve-fibres  of  different  sizes,  arranged  longitudinally,  and  of  a 
supporting  material  of  two  kinds,  viz. :  (a)  Ordinary  fibrous  con- 
nective-tissue sgepta  with  elastic  fibres,  which  is  connected  with 
ssepta  from  the  pia  mater,  passing  into  the  cord  to  carry  blood- 
vessels; (h)  neuroglia;  the  processes  of  the  neuroglia  cells  are 
arranged  so  as  to  support  the  nerve-fibres  which  are  without  the 
usual  external  nerve-sheaths.  The  gray  matter  of  the  cord  con- 
sists of  nerve-fibres,  most  of  which  are  very  fine  and  delicate,  of 
nerve-cells  with  branching  processes,  and  of  an  extremely  delicate 
network  of  the  primitive  fibrillse  of  axis  cylinders.  This  fine  net- 
work is  called  Gerlaclt's  netioorh,  and  is  mingled  with  the  meshes 
of  neuroglia.  The  neuroglia  of  the  gray  matter  resembles  that  in 
white  matter,  but  instead  of  everywhere  forming  a  close  network 
to  support  the  nerve-fibres,  here  and  there  it  is  in  the  form  of  a 
more  open  sponge-work  to  support  the  nerve-cells.  It  is  espo- 
cially  well  developed  around  ibo  central  canal,  l)eing  called  here 
tlie  suhstantia  gclatinosa  centralis.  At  the  tip  of  the  posterior 
horn  it  is  also  well  developed,  and  is  called  suhstantia  gelatinosa 
lateralis  of  Rolando.  The  latter  is  well  developed  in  the  cervical 
1* 


MARGINAL  ZONE, 
C  OR 

LISSAUER'S  TRACT. 


Fig.  4. — Showing  the  tracts  of  the  spinal  cord  and  their  varied  nomenclature. 
Red  =  motor  (or  efferent).     Blue  =  sensory  (or  afferent).     (Butler.) 

8 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTEY       9 

region.  The  gray  substance  is  thicker  in  the  lumbar  and  cervical 
regions  than  anywhere  else.  The  gray  substance  of  the  horns  or 
cornua  causes  the  anterior  horns  to  be  thicker  than  the  posterior. 
The  anterior  horns  do  not  quite  reach  the  free  surface  of  the 
cord,  while  the  posterior  horns  do. 

The  groups  of  cells  in  the  gray  matter  are  either  scat- 
tered singly  or  arranged  in  groups,  of  which  the  following 
are  to  be  distinguished  on  either  side.  The  nerve-cells  in  the 
anterior  horn  of  gray  matter  are  principally  large,  multipolar, 
ganglion  cells.  They  are  arranged  as  a  mesial  group,  near  the 
inner  aspect  of  the  horn,  and  an  anterior  and  a  lateral  group. 
The  column  of  Clarke  is  a  column  of  nerve-cells  situated  at 
the  junction  of  the  posterior  horn  with  the  gray  commissure. 
These  latter  cells  are  seen  only  in  the  thoracic  portion  of  the 
cord.  The  smallest  nerve-cells  are  found  in  the  posterior  horns 
of  the  cord. 

The  fibres  of  the  spinal  cord  are  of  two  kinds — the  extrinsic 
and  intrinsic.  The  extrinsic  fibres  begin  in  the  cerebrum  of  the 
braiii,  perhaps  in  the  cerebellum,  and  run  down  the  spinal  cord  to 
cells  therein.  The  intrinsic  fibres  connect  different  parts  of 'the 
spinal  cord  with  each  other. 

Differentiation  of  Tracts. — The  white  matter  can  be  systemat- 
ically divided  into  different  tracts  by  the  following  methods  of 
observation : 

1.  Emhrijological  Method. — It  has  been  found  by  examining 
the  spinal  cord  at  different  stages  of  its  development  that  certain 
groups  of  fibres  put  on  their  myelin  sheath  at  earlier  periods  than 
others,  and  that  the  different  groups  of  fibres  can  therefore  be 
traced  in  various  directions.  This  is  sometimes  called  the  Flechsig 
method. 

2.  Walleriaii  or  Degeneration  Method. — This  method  depends 
upon  the  fact  that  if  a  nerve-fibre  is  separated  from  its  nerve- 
cells  it  wastes  or  degenerates.  It  consists  in  tracing  the  course 
of  tracts  of  degenerated  fibres  which  result  from  an  injury  to  any 
part  of  the  central  nervous  system.  When  fibres  degenerate  below 
a  lesion,  the  tract  is  said  to  be  descending  degeneration,  and  when 
the  fibres  degenerate  in  an  opposite  direction,  the  tract  is  one  of 
ascending  degeneration. 

3.  Another  method  is  by  removing  an  organ  of  special  sense, 
and  then  tracking  the  degenerated  fibres. 


Fig. 


5.-Showing  the  functions  of  the  various  tracts  of  the  spinal  cord.     Red  =  n.otor 
(or  efferent).     Bhie  =  sensory  (or  afferent).     Compare  with  Fig.  4.     (Butler.; 

10 


ANxVTOMY,    PHYSIOLOGY,    AXD    CHEMISTRY       11 

Tracts  discovered  by  the  above  Methods  of  Determination. — 

The  spinal  cord  may  be  considered  as  a  series  of  segments  super- 
imposed one  upon  the  other,  corresponding  to  the  pairs  of  spinal 
nerves.  Each  of  these  sections  is  a  complete  centre,  is  sup- 
plied with  nerve-cells  and  with  motor  and  sensory  nerves.  The 
nerve-cells  are  grouped  into  motor  and  sensory  fields,  united 
by  the  intraspinal  fibres.  These  commissures  or  fibres  are  very 
short. 

1.  Anterior  Column. — This  is  composed  of  fibres  known  as 
the  commissural  fibres,  and  the  innermost  contribute  to  the  for-- 
mation  of  the  white  commissure  of  the  cord.  There  are  two  tracts 
located  in  the  anterior  column,  viz. :  on  either  side  of  the  anterior 
median  fissure  a  portion  of  the  column  is  taken  up  by  the  direct 
pyramidal  tract  (fasciculus  of  Turk),  which  can  be  traced  to 
be  continuous  with  the  non-decussating  fibres  of  the  pyramid  of 
the  medulla.  The  rest  of  the  anterior  column  is  composed  of 
fibres  of  the  anterior  lateral  ground  hundle.  The  anterior  column 
would  be  bounded  in  the  following  manner:  internally  by  the  an- 
terior median  fissure,  externally  by  the  anterior  horn  and  nerves 
springing  from  same,  and  anteriorly  by  the  free  surface  of  the 
cord.  It  may  be  stated  that  it  is  more  or  less  triangular  in  shape. 
Some  observers  claim  that  the  anterior  lateral  ground  hundle  is 
wholly  situated  in  the  lateral  column. 

2.  Lateral  Column. — This  column  is  composed  of  fibres  which 
are  larger  on  the  surface  of  the  cord  and  smaller  in  the  deeper 
portions.  There  is  no  decussation  in  the  spinal  cord  of  these 
fibres.  It  is  made  up  of  the  following  tracts,  viz. :  crossed  ■pyram- 
idal, direct  cerebellar,  anterior  lateral  ascending,  sometimes  called 

,  tract  of  Gowers,  anterior  lateral  descending,  sometimes  called 
tract  of  Lowenthal ;  Lissauer,  mixed  lateral  tract,  and  the  an- 
tero-lateral  ground  hundle.  The  direct  cerebellar,  or  tract  of 
Flechsig,  is  situated  at  the  posterior  superficial  part  of  the  lateral 
column.  This  extends  downward  as  far  as  the  second  lumbar 
nerve,  and  upward  as  far  as  the  restiform  body,  with  which  fibres 
it  passes  into  the  cerebellum.  Gowers's  tract  occupies  the  anterior 
superficial  surface  of  the  lateral  column.  It  commences  in  the 
lumbar  swelling  and  terminates  in  the  cerebellum,  passing  through 
the  superior  peduncles.  The  lateral  column  would  be  bounded  in 
the  following  manner:  internally  by  the  anterior  and  posterior 
horns  and  nerves  leading  from,  the  anterior  horn ;  externally  the 


ROOTS 


SPINOUS  PROCESS 


EXITS 


C   I  ARISES  ABOVE  ATLAS 

II  ARISES  OPPOSITE  ATLAS 

III  ARISES  AT  ATLAS 

IV  ARISES  BETWEEN  2nd  &  3rd  SPINE 
V  ,/       OPPOSITE  3rd  SPINE 


VI  u 

Til 

VIII       « 
D  I 
II 

III  .? 

TV  a 

V  „ 

VI 

VII 

VIII 

IX 

X 

XI 

XII 

LI   ) 
II  [      '. 

Ill-, 

IV  ^     „ 

V  ) 


S  I 

II 
III 

IV 


4th 

Sih 

6th 
6th 

7th  ,.       . 

1st  DORSAL  SPIN£. 
'2nd       « 

3rd        „  II 

4th 

5th        ,1 

6th 

7th        ,. 

8th 

9th 
10th 
11th 


■^\ 


Black  Dots  ==  Points  of  Origin. 
Circles-  Points  of  Exit, 
C  =  Cervical,  D  =  Dorsal. 

1,  =  Lumbar.  S  =  Sacral. 


BETWEEN  ATLAS  &  OCCIPUT 
ABOVE  ATLAS 


ABOVE  3rd  CERVICAL  SPINE 

4th 

i-i 

5th 

,■>                II 

6th 

.. 

7th 

II 

1st  DORSAL  SPINE 

BETWEEN  1st  &  2nd  DORSAL  SPINE 

2nd  II 

3rd        II 

3rd  II 

4th 

4th  „ 

5th         1,            II 

5th  ,, 

6th        1. 

6th  11 

7th         1, 

7th  „ 

8th         1, 

8th  „ 

9th 

9th  ,. 

10th       ,1           If 

10th  ,, 

11th       II 

11th  &  12th       „ 
BETWEEN   11th 
DORSAL   &   Ist  LUMBAR      i, 

1st  &  2nd        1, 

2ndi 

3rd        1. 

3rd  1 

4th 

4th  1 

5th 

BETWEEN   5th' 
LUMBAR   &   1st  SACRAL      ,i 

1st  &  2nd 

2nd, 

3rd       II 

3rd, 

4th        „ 

4th  , 

5th 

Fig.  6.— Diagram  showing  the  relation  of  the  segments  of  the  spinal  cord,  and  of  the  roots 
and  exits  of  the  spinal  nerves,  to  the  spinous  processes  of  the  vertebrse. 
18 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY       13 

lateral  column  is  comprised  between  the  lines  of  implantation 
of  the  anterior  and  posterior  roots. 

3.  Posterior  Column. — This  column  is  composed  of  fine  fibres, 
and  is  remarkable  for  its  abundance  of  neuroglia.  It  is  made  up 
of  the  following  tracts — GolVs  and  Burdaclis.  The  internal  col- 
umn, near  the  posterior  fissure,,  is  apparent  at  the  upper  part  of 
the  cord  in  the  form  of  a  slight  enlargement.  It  is  formed  of 
long  commissural  fibres.  The  fibres  rise  as  low  down  as  the  cauda 
equina,  and  run  up  to  the  nucleus  of  Goll  in  the  medulla  oblongata. 
The  tract  of  Burdach  is  developed  before  the  tract  of  Goll.  Bur- 
dach's  tract  terminates  in  the  nucleus  of  Burdach.  The  poste- 
rior column  would  be  bounded  in  the  following  manner :  inter- 
nally by  the  posterior  median  fissure,  externally  by  the  posterior 
horn,  and  posteriorly  by  the  free  margin  or  surface  of  the 
spinal  cord. 

The  gray  columns  of  cells  of  the  cord  are  ClarTie's,  and  inter- 
medio-lateral  tracts. 

Degenerations. — TTe  now  pass  from  this  to  consider  the  tracts 
of  degeneration  that  occur  when  the  spinal  cord  is  cut  right  across 
in  the  thoracic  region.  Some  tracts  will  be  found  degenerated  in 
the  piece  of  cord  below  the  lesion;  these  consist  of  nerve-fibres 
that  are  connected  with  the  nerve-cells  in  the  brain ;  they  are  called 
the  pyramidal  tracts.  Other  tracts  are  found  degenerated  in  the 
piece  of  cord  above  the  lesion ;  these  consist  of  fibres  that  are  con- 
nected with  the  nerve-cells  of  the  spinal  ganglia,  or  with  the  cells 
of  the  spinal  cord  itself  below  the  lesion,  and  are  passing  upward. 

The  tracts  which  degenerate  downward  are  the  motor  tracts; 
the  tracts  that  degenerate  upward  are  the  sensory  tracts. 

Tracts  of  Descending  Degeneration. — 1.  Crossed  Pyramidal 
Tract. — This  tract  is  situated  in  the  lateral  column  on  the  outer 
side  of  the  posterior  cornu  of  gray  matter.  At  the  lower  part 
of  the  spinal  cord  it  extends  to  the  margin,  but  higher  up  it 
becomes  displaced  from  this  position  by  the  interpolation  of  an- 
other tract  of  fibres,  viz.,  the  direct  cerebellar  tract.  The  crossed 
pyramidal  tract  is  large,  and  may  touch  the  gray  matter  at  the 
tip  of  the  posterior  cornu,  but  is  separated  from  it  elsewhere.  Its 
shape  on  cross-section  is  somewhat  like  a  lens,  but  varies  in  dif- 
ferent regions  of  the  cord,  and  diminishes  in  size  from  the  cervical 
region  downward,  its  fibres  passing  off  as  they  descend,  to  arborize 
around  the  nerve-cells  and  their  branchings  in  the  gray  matter 


14  TEEATISE    ON    NERVOUS    DISEASES 

of  the  cord.    The  fibres  of  which  this  tract  is  composed  are  mod- 
erately large,  but  are  mixed  with  some  that  are  smaller. 

2.  Direct  Pyramidal  Tract. — This  tract  is  situated  in  the  an- 
terior column  by  the  side  of  the  anterior  fissure.  It  is  small  in 
some  animals,  but  is  quite  conspicuous  in  the  human  spinal  cord. 
It  can  be  traced  upward  to  the  brain,  and  downward  as  far  as 
the  mid  or  lower  thoracic  region,  where  it  ends. 

The  two  pyramidal  tracts  come  down  from  the  brain;  in  the 
medulla  oblongata,  the  greater  number  of  the  pyramidal  fibres 
cross  over  to  the  other  side  of  the  cord  which  they  descend,  hence 
the  term  "  crossed  pyramidal '"  tract ;  a  smaller  collection  of  the 
pyramidal  fibres  goes  straight  on  on  the  same  side  of  the  cord,  and 
these  cross  at  different  levels  in  the  anterior  commissure  of  the 
cord  lower  down ;  hence  the  disappearance  of  the  direct  pyramidal 
tract  in  the  lower  part  of  the  cord. 

3.  Anterior  Lateral  Descending  Tract. — An  extensive  tract, 
elongated  but  narrow,  and  reaching  from  the  crossed  to  the  direct 
pyramidal  tract.  It  is  a  mixed  tract,  since  not  all  of  the  fibres 
degenerate  below  the  lesion. 

4.  Comma  Tract. — This  is  a  small  tract  of  fibres  which  degen-: 
erate  below  section  or  injury  of  the  cord.  It  is  only  found  for 
a  few  millimetres  below  the  actual  lesion,  though  it  degenerates 
downward;  it  is  in  reality  a  sensory  tract,  being  composed  of  the 
branches  of  the  entering  posterior  root-fibres  which  pass  down- 
ward on  entering  the  cord. 

Tracts  of  Ascending  Degeneration. — 1.  Gall. — This  degenerates 
upward  on  injury  or  on  section  of  the  cord,  as  well  as  on  section 
of  the  cord  from  below  upward,  and  can  be  traced  into  the  bulb. 
It  is  made  up  of  very  fine  fibres. 

2.  Direct  Cerebellar  Tract. — This  tract  is  situated  on  the  outer 
part  of  the  cord  between  the  crossed  pyramidal  tract  and  the 
margin.  It  is  found  in  the  cervical,  thoracic,  and  upper  lum- 
bar regions  of  the  cord,  and  increases  in  size  from  below 
upward.  It  degenerates  on  injury  or  section  of  the  cord  itself, 
but  not  on  section  of  the  posterior  nerve-roots.  As  its  name 
implies,  it  passes  up  into  the  cerebellum.  Its  fibres  are  large,  and 
originate  from  the  cells  of  Clarke's  column  of  the  same  side  of 
the  cord. 

3.  Anterior  Lateral  Ascending  Tract.— Thh  tract  is  situated 
at  the  margin  of  the  cord  outside  the  corresponding  descending 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTEY       io 

tract.  Its  fibres  are  of  various  sizes,  and  originate  from  cells 
situated  in  the  base  of  the  anterior  horn  of  the  opposite  side  of 
the  spinal  cord,  and  in  the  lower  thoracic  and  lumbar  regions;  the 
fibres  pass  through  the  gray  matter  or  commissure  and  anterior 
horn  of  the  opposite  side,  and  travels  up  as  the  tract  of  Gowers  to 
terminate  above,  principally  in  the  cerebellum. 

4.  Lissaue7''s  Tract. — This  is  a  small  tract  of  ascending  fibres, 
situated  at  the  outer  side  of  the  tip  of  the  posterior  cornu.  It  is 
made  up  of  fibres  of  the  posterior  nerve-roots. 

Complete  section  of  the  spinal  cord  (transverse)  leads  to: 

(a)  Loss  of  motion  of  the  parts  supplied  by  the  nerves  below 
the  section  on  both  sides  of  the  body.  The  paralysis  is  not  con- 
fined to  the  voluntary  muscles,  but  includes  the  muscular  fibres 
of  the  blood-vessels  and  viscera.  Hence  there  is  a  fall  of  blood- 
pressure,  paralysis  of  sphincters,  etc. 

(6)  Loss  of  sensation  in  the  same  regions. 

(c)  Degeneration,  descending  and  ascending,  on  both  sides  of 
the  cord. 

Hemisection. — If  the  operation  performed  is  not  a  complete 
cutting  of  the  spinal  cord  across  transversely,  but  a  cutting  of 
half  the  cord  across,  it  is  termed  hemisection.  This  operation 
leads  to : 

{a)  Loss  of  motion  of  the  parts  supplied  by  the  nerves  below 
the  section  on  the  same  side  of  the  body  as  the  injury. 

(6)  Loss  of  sensation  in  the  same  region.  The  loss  of  sensa- 
tion is  not  a  very  important  symptom,  and  is  limited  to  the  sense 
of  localization  and  the  muscular  sense.  The  animal  can  still  feel 
sensations  of  pain  and  of  heat  and  cold. 

(c)  Degeneration,  ascending  and  descending,  nearly  entirely 
confined  to  the  same  side  of  the  cord  as  the  injury. 

A  lesion  of  the  pyramidal  tract  in  the  cord  may  cause  liemi- 
plegia  or  paralysis  of  one  arm  or  leg,  called  monoplegia. 

When  the  motor  decussation  takes  place  in  the  anterior  pyra- 
mids, it  cuts  off  the  anterior  horns  of  the  spinal  cord,  forming  a 
number  of  nuclei  which  give  origin  to  motor  fibres  of  the  cranial 
nerves.  The  posterior  horns  are  cut  off  by  the  decussation  of  the 
fillet  and  give  sensory  nuclei  which  form  origins  to  the  cranial 
nerves. 

Medulla  Oblongata. — The  medulla  oblongata  is  the  upper  ex- 
pended part  of  the  spinal  cord.     It  connects  the  upper  part  of  the 


16  TEEATISE    OX    XEEYOUS    DISEASES 

spinal  cord  with  tlie  pons  varolii.  The  weight  of  the  medulla  is 
about  100  grains.  In  the  medulla,  the  fibres  from  the  cord  are 
rearranged,  the  gray  matter  is  also  much  changed,  while  new  gray 
matter  is  added.  Each  half  of  the  medulla  consists  of  the  follow- 
ing parts,  from  before  backward:  anterior  pyramid,  olivary  body, 
restiform  body,  funiculus  gracilis,  and  funiculus  cuneoius.  By 
the  divergence  of  the  posterior  columns  and  the  restiform  bodies, 
the  floor  of  the  fourth  ventricle  is  formed.  At  the  anterior  lower 
border  of  the  medulla  we  find  the  decussation  of  the  pyramids, 
where  the  fibres  cross  over  to  the  lateral  columns  of  the  cord. 
The  anterior  pyramid  receives  the  direct  pyramidal  tract  of  the 
anterior  column  of  the  cord  from  its  own  side,  and  the  crossed 
pyramidal  tract  from  the  lateral  column  of  the  cord  of  the  oppo- 
site side.  Most  of  the  pyramidal  fibres  pass  through  the  pons 
directly  to  the  cerebrum,  a  few  fibres  passing  to  the  cerebellum. 
The  anterior  median  fissure  of  the  spinal  cord  terminates  at  the 
foramen  caecum,  just  beneath  the  pons.  In  transverse  section  at 
the  level  of  the  inferior  olive  we  see  the  pyramids  in  front.  Ex- 
ternal to  the  pyramid,  on  either  side,  is  the  inferior  olive  with  its 
contained  nucleus  of  gray  matter  called  the  dentate  nucleus.  The 
formatio  reticularis  is  seen  in  the  centre  of  the  section.  Formatio 
reticularis  is  an  association  system  of  short  fibres  which  is  to  be 
met  with  at  any  point  between  the  spinal  cord  and  the  thalamus. 
These  fibres  run  at  right  angles  to  each  other.  Imbedded  in  it 
are  nerve-cells. 

The  restiform  body  is  composed  of  fibres  from  the  following 
sources : 

From  the  superior  olive. 

From  lateral  nucleus. 

From  the  direct  cerebellar  tract  of  the  same  side. 

From  the  nucleus  gracilis  and  nucleus  cuneatus  of  the  same 
side   (posterior  superficial  arcuate  fibres). 

From  the  nucleus  gracilis  and  nucleus  cuneatus  of  the  opposite 
side   (anterior  superficial  arcuate  fibres). 

From  lateral  nucleus  of  opposite  side. 

From  the  olivary  nucleus  by  fibres  which  pass  through  the 
opposite  olive,  superficial  to  the  opposite  olive,  and  deeper  than 
the  opposite  olive. 

The  funiculus  gracilis  of  the  medulla  is  composed  of  fibres 
which  occupy  the  column  of  Goll  in  the  spinal  cord. 


AXATOMY,    PHYSIOLOGY,    AND    CHEMISTRY       17 

The  funiculus  cuneatus  is  composed  of  fibres  wliicli  occaipy  tlie 
column  of  Burdach  in  the  spinal  cord. 

The  funiculus  of  Rolando  is  the  continuation  upward  into  the 
medulla  of  the  geUitinous  substance  capping  tlie  posterior  horns 
in  the  spinal  cord. 

The  medulla  is  about  1  inch  in  length,  f  of  an  inch  in  width, 
and  ^  an  inch  in  thickness.    It  has  four  faces. 

The  triangular  space  between  the  restiform  bodies  is  a  part 
of  the  floor  of  the  fourth  ventricle.  Eunning  transversely  across 
the  floor  of  the  fourth  ventricle  are  a  group  of  fibres  which  give 
partial  origin  to  the  auditory  nerve.  They  form  the  "  beard " 
of  the  fourth  ventricle.  Just  at  the  divergence  of  columns  of 
Goll  is  the  nib  of  the  fourth  ventricle,  called  the  calamus  scrip- 
torius. 

Centres  found  in  the  Medulla. — Eespiratory,  cardio-inhibitory, 
diabetic,  deglutition,  vaso-motor,  cardio-accelerator,  vomiting, 
salivation,  mastication. 

Pons  Varolii,  Etc. — This  is  situated  between  the  medulla  and 
the  crura  cerebri.  It  is  a  white  body  in  the  form  of  a  half  ring. 
Its  size  depends  upon  the  size  of  the  hemisphere  with  which  it 
has  to  do.  It  weighs  about  250  grains.  It  has  six  faces.  The 
anterior  face  rests  upon  the  basilar  process  of  the  occipital  bone, 
and  presents  a  median  groove  for  the  basilar  artery.  The  posterior 
surface  of  the  pons  forms  a  part  of  the  floor  of  the  fourth  ven- 
tricle. 

The  pons  is  formed  of  scattered  nerve-fibres  and  cells.  The 
transverse  fibres  which  form  the  cortex  go  for  the  most  part 
through  the  cerebellar  peduncles  to  the  hemispheres. 

There  are  three  planes  of  transverse  fibres:  first,  the  super- 
ficial, which  covers  the  pyramidal  columns ;  second,  the  one  known 
as  the  deep  stratum,  which  separates  the  pyramidal  tracts  from  the 
fillets;  and  the  third,  known  as  the  complex,  which  separates  the 
different  tracts.  On  transverse  section  we  see  that  the  organ  is 
divisible  into  an  anterior  portion  or  crusta,  and  a  posterior  por- 
tion or  tegmentum.  The  superior  olive  is  a  collection  of  gray 
matter.  The  trapezium  is  a  prominent  group  of  transverse  fibres 
running  from  the  accessory  nucleus  and  tuberculum  acusticum  to 
the  superior  olive  situated  in  front  of  the  tegmentum.  Numerous 
small  masses  of  gray  matter  are  found  in  the  pons,  which  are 
known  as  the  pontine  nuclei. 


18  TEEATISE    OX    XERVOUS    DISEASES 

The  pons  is  a  cross-way  for  the  conduction  of  motion  in  one 
direction  and  sensation  in  the  opposite;  and  besides  this  function 
of  the  pons  there  is  a  co-ordination  centre  in  the  pons  for  reflex 
actions.  Irritation  of  the  pons  will  cause  convulsions;  therefore 
it  contains  a  convulsive  centre. 

Cerebral  Peduncles. — The  cerebral  peduncles  extend  from  the 
superior  part  of  the  pons  to  the  optic  thalami,  and  their  size  is 
in  direct  relation  with  the  size  of  the  brain  proper.  They  are 
about  f  of  an  inch  in  length.  After  leaving  the  pons  they  are 
separated  from  each  other,  each  going  to  the  hemisphere  of  the 
respective  sides.  The  space  between  them  is  known  as  the  inter- 
peduncular space.  The  cerebral  peduncles  have  an  anterior  face, 
which  presents  a  longitudinal  groove.  The  external  face  is  em- 
braced in  great  part  by  the  hippocampal  convolution. 

Upon  transverse  section  we  see  a  black-looking  structure  which 
separates  the  crusta  from  the  tegmentum  and  is  known  as  the 
locus  niger,  dividing  the  pes  or  crusta  from  the  tegmentum.  The 
tegmentum  consists  of  masses  of  gray  matter  and  fibres  extending 
through  the  posterior  end  of  the  medulla  oblongata,  pons,  and 
crura  up  to  the  optic  thalami.  The  crusta  is  composed  of  two  bun- 
dles, the  internal  or  cortico-pontal,  which  goes  to  the  anterior  por- 
tion of  the  brain,  and  which  might  be  considered  as  a  commissure 
of  the  brain,  connecting  that  portion  with  the  gray  nuclei  in  the 
medulla  and  pons  and  the  cerebellum;  and  another,  the  external 
bundle  or  voluntary  motion  bundle,  which  comes  from  the  ascend- 
ing frontal  and  ascending  parietal  convolutions,  and  ends  in  the 
anterior  horns  of  the  spinal  cord.  The  external  bundle  contains  the 
geniculate  bundle.  This  starts  in  the  cortex  around  the  speech 
centre,  and  ends  in  the  hypoglossal,  facial,  and  trigeminal  nuclei. 

In  the  peduncle  is  seen  the  nucleus  ruler,  which  is  composed 
of  a  mass  of  red  fibres  and  cells,  and  in  which  ends  the  superior 
cerebellar  peduncle. 

In  the  tegmentum  of  the  peduncle  are  also  sensory  fibres.  In 
the  tegmentum  are  three  masses  of  longitudinal  fibres,  viz.,  the 
posterior,  the  central,  and  superior. 

There  are  three  fillets.  The  median  or  upper,  which  rises 
from  Goll  and  Burdach's  nuclei  and  runs  on  through  the  teg- 
mentum chiefly,  and  in  lateral  nucleus  of  optic  thalamus,  and 
then  enters  the  cortex  of  the  brain.  The  lateral  -fillet,  which  starts 
from  Goll  and  Burdach's  nuclei,  runs  to  the  superior  olive  and 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY       19 

ends  in  the  posterior  corpus  quadrigeminum.  It  is  composed  of 
fibres  concerned  in  hearing.  The  mesial  fillet  comes  from  the 
same  source  as  the  others.    It  terminates  in  the  base  of  cerebrum. 

Capsules  of  the  Brain. — They  are  the  internal  and  external. 
The  internal  capsule  is  composed  of  a  band  of  white  fibres,  being 
divided  into  an  anterior  and  a  posterior  segment.  The  point  where 
the  segments  are  united  is  known  as  the  genu.  The  internal  cap- 
sule is  bounded  internally  by  the  optic  thalamus  and  caudate  nu- 
cleus, externally  by  the  lenticular  nucleus.  The  fibres  composing 
the  anterior  segment  of  the  internal  capsule  are  the  cortico-pontal 
fibres  anteriorly  and  the  geniculate  tract  posteriorly.  In  other 
words,  the  geniculate  tract  lies  just  in  front  of  the  genu.  The 
posterior  segment  of  the  internal  capsule  is  made  up  of  motor 
fibres  for  its  anterior  two-thirds,  and  sensory  for  the  posterior  one- 
third.  The  motor  tract  has  the  following  origin  and  distribution : 
From  ascending  frontal,  ascending  parietal  convolutions  (motor 
area),  through  anterior  two-thirds  of  posterior  segment  of  internal 
capsule,  thence  through  crura,  pons,  anterior  pyramids  of  medulla, 
and  there  decussate.  Crossed  pyramidal  portion  goes  down  oppo- 
site lateral  column;  direct  pyramidal  portion  goes  down  the  same 
side,  both  tracts  ending  finally  in  the  anterior  horns  for  further 
distribution.  The  sensory  tract  is  traced  as  follows:  From  occip- 
ital, parietal,  and  temporal  lobes,  through  posterior  third  of  in- 
ternal capsule  (posterior  segment)  into  peduncle,  divides,  the 
main  part  goes  through  tegmentum  to  nuclei  of  Goll  and  Burdach, 
down  posterior  columns  through  ganglion  of  posterior  root  to 
skin.  The  rest  or  remainder  of  the  sensory  fibres  go  through  the 
lateral  columns  for  further  distribution. 

The  external  capsule  is  a  band  of  fibres  bounded  laterally  or 
internally  by  the  lenticular  nucleus  and  externally  by  the  clau- 
strum. 

Cerebellum. — The  cerebellum  is  composed  of  an  elongated  cen- 
tral portion  or  lobe,  called  the  vermiform  process,  and  two  lateral 
hemispheres.  Each  hemisphere  is  connected  with  its  fellow  not 
only  by  means  of  the  vermiform  process,  but  also  by  a  bundle  of 
fibres  called  the  middle  peduncle  (the  latter  forming  the  greater 
part  of  the  transverse  fibres  of  the  pons),  while  the  superior 
peduncles,  which  decussate  in  the  micl-brain,  connect  it  with  the 
cerebrum,  and  the  inferior  peduncles  (restiform  bodies)  connect  it 
with  the  medulla  oblongata. 


20  TEEATISE    OK    NERVOUS    DISEASES 

The  cerebellum  is  composed  of  white  and  gray  matter,  the 
latter  being  external,  like  that  of  the  cerebrum,  and,  like  it,  in- 
folded so  that  a  larger  area  may  be  contained  in  a  given  space. 
The  tree-like  arrangement  of  the  white  matter  has  given  rise  to 
the  name  arho7'  vitce.  Besides  the  gray  matter  on  the  surface, 
there  are  in  the  centre  of  the  white  substance  of  each  hemisphere 
small  masses  of  gray  matter,  the  largest  of  which  is  called  corpus 
dentatum.  The  others  are  called  nucleus  glo'bosus,  nucleus  fastigii, 
and  nucleus  emholiformis. 

If  a  section  is  taken  through  the  cortical  portion  of  the  cere- 
bellum, the  following  distinct  layers  can  be  seen  by  the  micro- 
scope. 

Underneath  the  pia  mater  is  the  external  layer  of  gray  matter ; 
it  is  formed  chiefly  of  fine  nerve-fibres  with  small  nerve-cells  scat- 
tered through  it.  Into  its  outer  part  processes  of  pia  mater  pass 
vertically;  these  convey  blood-vessels.  There  are  also  here  numer- 
ous long  tapering  neuroglia  cells.  The  internal  or  granular  layer 
of  gray  matter  is  made  up  of  a  large  number  of  small  nerve-cells 
mixed  with  a  few  larger  ones,  and  some  neuroglia  cells.  Between 
the  two  laj'ers  is  an  incomplete  stratum  of  large  flask-shaped  cells 
called  the  cells  of  Purhinje.  Each  of  these  gives  off  from  its 
base  a  fine  process  which  becomes  the  axis  cylinder  of  one  of  the 
medullated  fibres  of  the  white  matter;  the  neck  of  the  flask 
passing  in  the  opposite  direction  breaks  up  into  dendrites,  which 
pass  into  the  external  layer  of  gray  matter.  Each  cell  of  Pur- 
kinje  is  further  invested  by  arborizations  of  two  sets  of  nerve- 
fibres.  One  of  these  (originating  from  the  fibres  of  the  white 
matter  which  are  not  continuous  as  axis  cylinders  from  the 
cells  of  Purkinje)  forms  a  basket-work  round  the  dendrons;  the 
other  (originating  as  axis-cylinder  processes  from  the  nerve-cells 
of  the  external  layer)  forms  a  felt-work  of  fibrils  round  the  body 
of  the  cell. 

The  cells  of  the  internal  layer  of  gray  matter  are  small ;  their 
dendrites  intermingle  with  those  of  neighbouring  cells ;  their  ax- 
ones  penetrate  into  the  external  layer,  but  their  final  destination  is 
uncertain.  Ramifying  among  these  cells  are  fibres  characterized 
by  possessing  bunches  of  short  branches  at  intervals. 

Cerebrum. — The  cerebrum  consists  of  two  halves  called  cere- 
bral hemispheres,  separated  by  a  longitudinal  fissure  and  con- 
nected by  a  large  band  of  transverse  commissural  fibres  known  as 


AXATOMY,    PHYSIOLOGY,    AXD    CHEMISTRY       21 

the  corpus  callosum.  The  interior  of  each  hemisphere  contains 
a  cavity  of  complicated  shape  called  the  lateral  ventricle. 

Each  hemisphere  is  covered  with  gray  matter^  which  passes 
down  into  the  fissures  that  abound  on  it?  exterior.  The  amount 
of  this  gray  matter  varies  directly  with  the  amount  of  convolu- 
tions of  the  surface.  Under  it  white  matter  is  situated,  and  at 
the  hase  there  are  masses  of  gray  matter ;  parts  of  these  basal  gan- 
glia are  seen  forming  part  of  the  wall  of  the  ventricles.  The  an- 
terior basal  ganglion  is  called  the  corpus  striatum  :  it  is  divided 
into  two  parts,  called  the  lenticular  nucleus  and  the  caudate  nu- 
cleus.    The  posterior  basal  ganglion  is  called  the  optic  thalamus. 

Passing  between  the  basal  ganglia  are  the  white  fibres,  which 
enter  the  cerebral  hemispheres  from  the  crus;  these  constitute  the 
internal  capsule   (already  explained). 

The  brain  cortex  has  four  layers,  as  follows :  1,  molecular 
layer,  containing  caudal  cells;  2,  lajer  of  small  pyramidal  cells; 
3,  layer  of  large  pyramidal  cells  and  cells  of  Martinotti  whose 
axones  run  upward  to  the  first  or  molecular  layer:  4.  layer  of 
polymorphous  cells. 

The  outer  or  external  surface  of  the  brain  presents  numerous 
depressions  and  elevations,  the.  latter  being  known  as  convolutions. 
Each  cerebral  hemisphere  is  divided  into  lobes,  which  are  further 
divided  by  many  depressions  or  fissures  into  convolutions.  The 
cause  of  folding  of  the  cerebral  substance  is  due  to  the  rigidity 
of  the  cranium  during  development. 

There  are  five  great  fissures,  viz.,  the  great  longitudinal,  the 
great  transverse,  fissure  of  Sylvius,  fissure  of  Eolando,  and  the 
occipito-parietal. 

The  fissure  of  Eolando  commences  at  the  great  longitudinal 
fissure,  and  runs  downward,  terminating  above  the  horizontal  limb 
of  the  fissure  of  Sylvius. 

The  weight  of  the  brain  is  about  52  ounces.  In  rare  cases  it 
may  reach  65  ounces.  It  is  heavier  in  civilized  than  uncivilized 
races ;  greater  in  the  male  than  in  the  female. 

Optic  Tlialami. — The  optic  thalami  are  about  the  size  of  pig- 
eons' eggs,  and  are  directed  obliquely  forward  and  inward,  and 
approach  each  other  at  their  anterior  extremities.  Between  them 
lies  the  third  ventricle. 

The  thalami  have  three  nuclei,  viz..  external,  or  lateral  nu- 
cleus of  Flechsig,  internal,  and  anterior.  The  lateral  nuclei  are 
3 


22  TREATISE    OX    XEEVOUS    DISEASES 

the  points  of  attachment  of  the  posterior  roots.  The  other  nuclei 
do  not  have  anything  to  do  with  the  posterior  roots. 

There  are  some  cells  between  the  pulvinar  and  the  origin  of  the 
peduncle  of  the  pineal  gland,  called  the  hahennla.  There  is  also 
a  nucleus  known  as  the  nucleus  of  the  habenula. 

Corpora  Quadrigemina,  Etc. — These  are  four  small  bodies,  sepa- 
rated from  the  aqueduct  of  Sylvius  by  the  lamina  quadrigemina. 
The  anterior  pair  are  connected  by  the  superior  brachia  with  the 
external  geniculate  todies.  The  posterior  pair  are  connected  by 
the  inferior  brachia  to  the  internal  geniculate  bodies.  The  anterior 
corpora  quadrigemina  are  principally  concerned  in  sight,  while 
the  posterior  are  concerned  principally  in  hearing. 

Corpus  Striatum. — This  is  so  called  from  the  fact  that  white 
fibres  of  the  internal  capsule  pass  through  it.  They  are  situated 
a  little  in  front  and  slightly  outward  from  the  optic  thalami. 
The  nuclei  composing  these  bodies,  as  before  stated,  are  the  lentic- 
ular and  caudate. 

Membranes  of  the  Brain  and  Cord. — The  brain  and  spinal  cord 
are  enveloped  in  three  membranes:  1,  dura  mater;  2,  arachnoid; 
3,  pia  mater. 

1.  The  dm'a  mater  or  external  covering  is  a  tough  membrane 
composed  of  bundles  of  connective  tissue  which  cross  at  various 
angles,  and  in  whose  interstices  branched  connective-tissue  cor- 
puscles lie;  it  is  lined  by  a  thin,  elastic  membrane  on  the  inner 
surface  of  which  is  a  layer  of  endothelial  cells.     , 

2.  The  arachnoid  is  a  more  delicate  membrane,  very  -simple, 
and  similar  in  structure  to  the  dura  mater,  and  lined  on  its  outer 
free  surface  by  an  endothelial  membrane. 

3.  The  pia  mater  consists  of  two  chief  layers,  between  which 
numerous  blood-vessels  ramify.  Between  the  arachnoid  and  the 
pia  mater  is  a  network  of  fibrous  tissue  trabeculas  sheathed,  with 
endothelial  cells;  these  suharachnoid  traheculce  divide  up  the  sub- 
arachnoid space  into  a  number  of  irregular  sinuses.  There  are 
some  similar  trabecul^e,  but  fewer  in  number,  traversing  the  sub- 
dural space,  i.  e.,  the  space  between  the  dura  mater  and  arachnoid. 

Section  II. — Physiology 

Physiology  of  the  Nervous  System. — Functions  of  the  Spinal 
Cord. — It  is  a  great  conducting  medium,  carrying  impulses  up- 


AXATOMY,    PHYSIOLOGY,    AND    CHEMISTRY'       23 

ward  and  downward,  and  within  itself  from  side  to  side;  it  is  the. 
great  reflex  centre,  or  rather  series  of  so-called  reflex  centres.    Im- 
pulses originate  within  it  a  function  of  minor  importance,  how- 
ever. 

Spinal  Reflexes. — By  reflex  action  or  movement  is  meant  a 
movement  caused  by  the  stimulation  of  an  afferent  (sensory) 
nerve.  The  simplest  definition  is ;  a  reflex  action  is  an  afferent 
impulse  followed  by  an  efferent  impulse.  Another  definition  is : 
a  reflex  act  is  the  transmission  of  irritation  by  the  neuraxone  of  a 
sensory  neurone  to  the  dendrones  of  the  motor  neurone,  and  by  its 
neuraxone  to  the  muscle. 

The  stimulus,  on  being  applied  to  an  afferent  nerve,  sets  up 
a  state  of  excitement  (nervous  impulse)  in  that  nerve,  which 
state  of  excitement  is  transmitted  or  conducted  in  a  centripetal 
direction  along  the  nerve  to  the  centre  (spinal  cord)  ;  where  the 
nerve-cells  represent  the  nerve-centre  in  the  cord,  the  impulse  is 
transferred  to  the  motor,  efferent,  or  centrifugal  channel.  Three 
factors,  therefore,  are  essential  for  a  reflex  motor  act — afferent 
fibre,  a  transferring  centre,  and  an  efferent  fibre;  these  together 
constitute  a  reflex  arc. 

In  a  purely  reflex  act  all  voluntary  activity  is  excluded.  Ee- 
ilex  movements  may  be  divided  into  three  classes,  as  follows : 

a.  The  simple  or  partial  reflexes,  which  are  characterized  by 
the  fact  that  stimulation  of  a  sensory  area  discharges  movement 
in  one  muscle  only,  or  at  least  in  one  limited  group  of  muscles. 

h.  The  extensive  inco-ordinate  reflexes,  or  reflex  spasms. 
These  movements  occur  in  the  form  of  clonic  or  tetanic  contrac- 
tions; individual  groups  of  muscles,  or  all  the  muscles  of  the  body 
may  be  implicated. 

c.  Extensive  co-ordinated  reflexes  are  due  to  stimulation  of  a 
sensory  nerve,  causing  the  discharge  of  complicated  reflex  move- 
ments in  whole  groups  of  different  muscles,  the  movements  being 
""  purposive  "  in  character,  i.  e.,  as  if  they  were  intended  for  a 
particular  purpose. 

If  an  electric  irritant  is  applied  to  a  motor  nerve  there  will 
be  a  greater  contraction  of  the  muscle  than  if  the  irritant  was 
applied  directly  to  the  muscle  itself. 

In  reflex  action  are  three  elements :  first,  the  external  irrita- 
tion; second,  excitation  of  nerve-centres  themselves;  third,  con- 
tractions of  the  muscles. 


24  TREATISE    O^t    NERVOUS    DISEASES 

The  seat  of  reflex  action  is  mainl}^  in  the  cord,  although  some 
centres  are  found  in  the  medulla  and  pons  varolii. 

PflUger's  Laws  of  Reflex  Action. — 1.  The  reflex  movement  oc- 
curs on  the  same  side  on  which  the  sensor}^  nerve  is  stimulated, 
while  only  those  muscles  contract  whose  nerves  arise  from  the 
same  segment  of  the  spinal  cord.  ' 

2.  If  the  reflex  occurs  on  the  other  side,  only  the  corresponding 
muscles  contract. 

3.  If  the  contractions  be  unequal  upon  the  two  sides,  then  the 
most  vigorous  contractions  always  occur  on  the  side  which  is 
stimulated. 

4.  If  the  reflex  excitement  extend  to  other  motor  nerves,  those 
nerves  are  always  affected  which  lie  in  the  direction  of  the  me- 
dulla oblongata.  Lastly,  all  the  muscles  of  the  body  may  be 
thrown  into  contraction. 

In  the  spinal  cord  reflex  impressions  pass  at  the  rate  of  20 
feet  per  second. 

Inhibition  of  the  Reflexes. — Within  the  body  there  are  mechan- 
isms which  can  suppress  or  inhibit  the  discharges  of  reflexes,  and 
they  may  therefore  be  termed  mechanisms  inhibiting  the  reflexes. 
These  are : 

1.  Voluntary  Inliihition. — Reflexes  may  be  inhibited  voluntar- 
ily, both  in  the  region  of  the  spinal  cord  and  brain.  Example : 
Keeping  the  eyelids  open  when  the  eyeball  is  touched;  arrest  of 
movement  when  skin  is  tickled.  We  must  observe,  however,  that 
the  suppression  of  the  reflexes  is  possible  only  up  to  a  certain 
degree. 

2.  Setsclienow's  Inhibitory  Centres. — They  are  located  in  the 
corpora  quadrigemina  and  the  optic  thalami. 

3.  Strong  stimulation  of  a  sensory  nerve  inhibits  reflex  move- 
ments. The  reflex  does  not  take  place  if  an  afferent  nerve  be 
stimulated  very  powerfully.  Example:  Suppressing  a  sneeze  by 
friction  of  the  nose:  suppression  of  the  movements  produced  by 
tickling,  by  biting  the  tongue. 

4.  Poisons. — Chloroform  diminishes  the  reflex  excitability  by 
acting  upon  the  centres. 

A  constant  current  of  electricity  passed  longitudinally  through 
the  cord  diminishes  the  reflexes,  especially  if  the  direction  of  the 
current  is  from  above  downward. 

Some  drugs  affect  the  reflex  excitability  directly  by  acting  on 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTKY       2o 

the  spinal  cord — e.  g.,  niethylconine — but  other  drugs  may  produce 
the  same  result  indirectly  by  affecting  the  heart  and  the  blood 
supply  to  the  cord.  If  the  abdominal  aorta  be  compressed  for  a 
few  minutes  to  cut  off  the  blood  supply  to  the  cord  and  lower 
limbs,  paraplegia  is  temporarily  produced.  Blood  is  absolutely 
necessary  for  the  maintenance  of  function  in  the  cord.  If  the  sup- 
ply'be  cut  off  from  the  brain,  the  person  will  lose  consciousness 
in  four  seconds.  Anaemia  will  stimulate  reflex  actions  for  a  cer- 
tain time.  If  the  excitation  is  carried  to  a  great  degree  the  cord 
will  become  fatigued.  If  the  spinal  cord  is  cut  in  the  lumbar 
region  there  will  be  a  rhythmic  action  of  the  sphincters.  Strych- 
nine is  poisonous  to  every  nerve-cell,  while  cliloroform  is  poisonous 
to  every  cell  both  of  plants  and  animals. 

According  to  Broivn-Sequard,  reflex  activity  is  most  marked 
in  birds,  amphibians,  reptiles,  next  in  mammals  and  fishes.  In 
the  new-born  it  is  always  very  great. 

The  physician,  by  studying  the  condition  of  the  reflexes,  can 
form  an  idea  as  to  the  condition  of  (practically)  every  inch  of  the 
spinal  cord.     The  following  reflexes  have  been  noted: 

1.  Plantar  Refl.ex. — Obtained  by  tickling  the  sole  of  the  foot. 
Centre  in  the  lumbar  region. 

2.  Patellar  Reflex. — Obtained  by  striking  the  tendon  above 
or  below  the  patella.  Centre  between  second  and  third  lumbar 
nerves. 

'  3.  Cremasteric  Reflex. — Obtained  by  tickling  or  pinching  the 
inside  of  the  thigh ;  the  testicle  is  drawn  up.  Centre  in  the  lumbar 
.region,  between  second  and  third  lumbar  nerves. 

4.  Abdominal  Reflex. — Obtained  from  a  sharp  push  in  the  ab- 
domen, causing  contraction  of  the  abtlominal  muscles.  Centre 
between  eighth  and  twelfth  dorsal  nerves. 

5.  Epigastric  Reflex.— li  the  skin  is  excited  between  the  fourth, 
fifth,  and  sixth  intercostal  spaces,  there  will  be  a  contraction  of 
the  rectus  abdominis.  Centre  between  fourth  and  eighth  dorsal 
nerves. 

6.  Scapular  Reflex. — On  irritating  the  skin  over  the  scapula 
there  will  be  a  contraction  of  the  shoulder  muscles.  Centre  be- 
tween seventh  and  eighth  cervical  and  second  dorsal  nerves. 

7.  Cilio-spinal  Reflex. — If  the  skin  of  neck  is  pinched  there 
will  be  a  dilatation  of  the  pupil.  Centre  between  sixth  cervical 
and  third  dorsal  nerves, 


26  TREATISE    OX    XERVOUS    DISEASES 

Other  Reflex  Centres  in  the  Spinal  Cord. — a.  Ano-spinal  cen- 
tre, or  centre  controlling  the  act  of  defecation. 

t.  Vesicospinal  centre  for  regailating  micturition. 

c.  Erection  or  genito-spinal  centre,  located  in  the  lumbar  re- 
gion. The  afferent  nerves  are  the  sensory  nerves  of  the  penis;  the 
efferent  nerves  for  the  deep  arterj^  of  the  penis  are  the  vaso-dilator 
nerves  arising  from  the  first  to  the  third  sacral  nerves. 

d.  Ejaculation  Centre. — The  afferent  nerve  is  the  dorsal  nerve 
of  the  penis;  the  centre  lies  at  the  fourth  lumbar  vertebra;  the 
motor  fibres  of  the  vas  deferens  arise  from  the  fourth  to  the  fifth 
lumbar  nerves,  which  pass  into  the  S3'mpathetic,  and  from  thence 
into  the  vas  deferens.  The  motor  fibres  for  the  bulbo-cavernosus 
muscle,  which  ejects  the  semen  from  the  bulb  of  the  urethra,  lie  in 
the  third  and  fourth  sacral  nerves. 

e.  Vaso-rnotor  Centres. — Both  vaso-constrictor  and  vaso-dilator 
centres  are  distributed  throughout  the  whole  of  the  spinal  axis. 

/.  Siveat  Centres. — These  are  located  in  the  spinal  cord. 

g.  Parturition  Centre. — This  lies  at  the  first  and  second  lumbar 
vertebra ;  the  afferent  fibres  come  from  the  uterine  plexus,  to  which 
also  the  motor  fibres  proceed.  Goltz  observed  that  a  bitch  became 
pregnant  after  its  spinal  cord  was  divided  at  the  first  lumbar 
vertebra. 

Excitability  of  the  Spinal  Cord. — Even  at  the  present  time  ob- 
servers are  by  no  means  agreed  whether  the  spinal  cord,  like  the 
peripheral  nerves,  is  excitable,  or  whether  it  is  distinguished  by  the 
remarkable  peculiarity  that  most  of  its  conducting  paths  and  gan- 
glia do  not  react  to  direct  electrical  and  mechanical  stimuli.  It 
is  contended  by  most  observers  that  if  stimuli  be  cautiously  ap- 
plied either  to  white  or  gra}^  matter,  there  is' neither  movement 
nor  sensation.  As  the  spinal  cord  conducts  to  the  brain  impulses 
communicated  to  it  from  the  stimulated  posterior  roots,  but  does 
not  itself  respond  to  stimuli  which  produce  sensations,  Schiff  has 
applied  to  it  the  term  cesthesodic.  Further,  as  the  cord  can  con- 
duct both  voluntary  and  reflex  motor  impulses  without,  however, 
itself  being  affected  by  stimuli  applied  to  it  directly,  he  called  it 
hinesodic. 

The  following  views  have  been  expressed: 

1.  In  the  posterior  columns  the  sensory  root-fibres  of  the  pos- 
terior root  which  traverse  these  columns  give  rise  to  painful  im- 
pressions, but  the  proper  paths  of  the  posterior  columns  them- 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTEY       27 

selves  do  not  do  so.  Eemoval  of  the  posterior  column  produces 
ancEsthesia  (loss  of  tactile 'sensation).  Algesia  (or  the  sensation 
of  pain)  remains  intact,  although  at  first  there  may  even  be 
hyperalgesia. 

The  trophic  centres  of  posterior  roots  are  the  posterior  root 
ganglia. 

2.  The  anterior  columns  are  non-excitable,  both  for  striped 
and  non-striped  muscle,  as  long  as  the  stimuli  are  applied  only 
to  the  proper  paths  of  these  columns.  But  movements  may  follow 
either  when  the  anterior  nerve-roots  are  stimulated  or  when,  by 
the  escape  of  the  current,  the  posterior  columns  are  affected,  where- 
by reflex  movements  are  produced. 

The  trophic  centres  of  anterior  roots  are  the  anterior  horns. 

3.  The  vaso-constrictor  nerves^,  which  proceed  from  the  vaso- 
motor centre  and  run  downward  in  the  lateral  columns  of  the 
cord,  are  excitable  by  all  stimuli  along  their  whole  course;  direct 
stimulation  of  any  transverse  section  of  the  cord  constricts  all 
the  blood-vessels  below  the  point  of  section.  In  the  same  way,  the 
fibres  which  ascend  in  the  cord  and  increase  the  action  of  the  vaso- 
motor centre  are  also  excitable.  Stimulation  of  these  fibres,  al- 
though it  affects  the  vaso-motor  centre  reflexly,  does  not  cause 
sensation. 

4.  Chemical  stimuli,  such  as  the  application  of  salt  or  wetting 
the  cut  surface  with  blood,  appear  to  excite  the  spinal  cord  some- . 
what, 

5.  The  motor  centres  are  directly  excited  by  blood  heated  to 
about  40°  C,  or  by  asphyxiated  blood,  or  by  sudden  and  complete 
anaemia  of  the  cord  produced  by  ligature  of  the  aorta,  and  also 
by  certain  poisons.  Picrotoxin,  nicotine,  and  compounds  of  bari- 
um seem  also  to  produce  the  effect. 

Paths  of  Spinal  Cord  for  Pain,  Heat,  and  Cold;  Muscular  and 
Tactile  Sensations. — Pain,  heat,  and  cold  impressions  pass  through 
the  gray  matter  of  the  spinal  cord  from  cell  to  cell. 

Muscular  and  tactile  sensations  are  transmitted  through  or  by 
the  white  matter  of  the  cord. 

Vaso-motor  nerves  come  down  the  lateral  columns  in  the  gray 
substance  to  the  anterior  roots. 

The  nerves  from  the  centre  of  respiration  run  through  the 
lateral  columns  and  then  enter  the  gray  substance  of  the  anterior 
liorns  and  leave  by  the  anterior  roots. 


38  TREATISE    ON    NERVOUS    DISEASES 

The  s7/jeat  and  inJiihitory  fibres  runniiag  down  the  lateral  col- 
umns hoth  decussate,  the  former  in  the  cord  and  the  others  in 
the  medulla.  The  sweat  fibres  pass  out  from  the  anterior  roots, 
also  the  branches  which  make  up  the  splanchnics. 

There  is  one  sensory  decussation  in  the  fillet  fibres. 

There  are  two  motor  decussations :  the  lower  one  is  in  the  cord, 
in  the  anterior  commissure,  while  the  higher  is  in  the  anterior 
pyramids. 

Locomotor  Ataxia. — In  locomotor  ataxia  there  is  a  degenera- 
tion of  the  lower  part  of  the  posterior  column.  Tactile  and  mus- 
cular sensations  are  abolished.  Pain,  heat,  and  cold  sensations, 
however,  are  still  transmitted,  as  a  rule. 

Syringomyelia. — This  is  a  disease  of  the  gray  tract,  with 
gliosis  arnd  final  cavity  formation.  Sensations  of  heat,  pain,  and 
cold  are  abolished,  while  tactile  and  muscular  sensations  are  still 
transmitted. 

When  there  is  a  lesion  in  the  jons,  there  is  a  paralysis  of  the 
face  on  one  side  and  of  the  arm  and  leg  on  the  opposite  side. 
This  is  known  as  crossed  hemiplegia. 

Monoplegia  is  paralysis  of  certain  areas  alone,  as  in  the  leg, 
arm,  etc.,  due  to  haemorrhage  in  the  brain  or  disease  of  certain 
parts  of  the  motor  area. 

There  is  a  plentiful  supply  of  blood-vessels  in  all  portions  of 
the  brain.  Both  the  caudate  and  lenticular  nuclei  are  supplied  by 
'  the  middle  cerebral  artery.  There  are  three  lenticular  branches ; 
one  of  these  is  known  as  the  lenticulo-striate  artery  of  cerebral 
haemorrhage.  It  is  sometimes  called  Charcot's  artery  of  cerebral 
hsemorrhage. 

The  brain  has  no  true  lymphatics,  but  both  in  the  brain  and  cord 
are  the  perivascular  lymph  spaces  of  His  which  carry  the  lymph. 

Nerve-Fibres,  runction  of. — A  nerve  wave  is  a  transmission  of 
nerve  force  through  the  axis  cylinder  of  a  nerve.  This  brings  out 
the  properties  of  nervous  excitability.  The  laws  of  nervous  con- 
ductivity are :  First,  the  integrity  of  the  nerve ;  the  neuraxone  must 
be  intact.  Second,  isolated  conduction ;  a  nerve-fibre  carries  an  im- 
pression without  its  being  diffused  to  other  nerves.  Third,  the  law 
of  conduction  in  both  directions;  if  a  nerve  is  irritated,  the  im- 
pression may  be  carried  both  ways. 

Sensory  and  motor  nerves  are  of  the  same  nature  and  structure, 
but  they  are  attached  to  different  forms  of  -apparatus. 


AI^ATOMY,    PHYSIOLOUY,    AND    CHEMISTEY      29 

Electricity  travels  ten  million  times  faster  than  nerve  waves. 

Irritability  is  a  fundamental  property  of  nerves.  After  a  nerve 
is  cut  and  separated  from  the  circulation,  it  will  retain  its  irrita- 
bility for  some  time,  but  eventually  loses  it.  The  Esmarch  bandage 
will  cause  this  phenomenon.  When  a  nerve  is  cut,  the  first  thing 
is  a  rise  of  irritability,  soon  followed  by  its  loss.  Woorara  para- 
lyzes the  terminations  of  the  motor  nerves  in  the  muscles.  In  sym- 
metrical gangrene  there  is  a  slow  stoppage  of  the  circulation,  and 
the  pain  is  very  acute.  The  patient  suffers  first  from  hyperses- 
thesia,  but  this  soon  disappears.  When  a  mixed  nerve  is  irritated, 
there  is  first  an  anaesthesia  and  then  a  paralysis.  Heat  causes  nerv- 
ous excitability  and  cold  renders  a  part  insensible,  and  if  carried 
to  excess  causes  temporary  paralysis.  Inflammation  causes  great 
irritation  to  the  nerves.  When  such  nerves  are  incised  there  is 
much  more  pain  than  in  healthy  tissue.  Nerves  possess  the  prop- 
erty of  being  thrown  into  a  state  of  excitement  by  stimuli,  and  are 
therefore  said  to  be  excitable.  The  stimuli  may  be  applied  to  and 
may  act  upon  any  part  of  the  nerve.  The  following  are  the  various 
kinds  of  stimuli — i.  e.,  modes  of  motion — which  act  upon  the 
nerves : 

1.  Mechanical  stimuli  act  upon  nerves  when  they  are  applied 
with  sufficient  rapidity  to  produce  a  change  in  the  form  of  the 
nerve  particles,  such  as  pressure,  pinching,  tension,  puncture,  etc. 
In  the  case  of  sensory  nerves,  when  they  are  stimulated  pain  is 
produced,  as  is  felt  when  a  limb  "  sleeps,"  or  when  pressure  is  ex- 
erted upon  the  ulnar  nerve  at  the  bend  of  the  elbow.  When  a 
motor  nerve  is  stimulated,  motion  results  in  the  muscle  attached 
to  the  nerve.  If  the  continuity  of  the  nerve-fibres  be  destroyed,  the 
conduction  of  the  impulse  across  the  injured  part  is  interrupted. 
Continued  pressure  upon  a  mixed  nerve  paralyzes  the  motor  fibre 
sooner  than  the  sensory  fibres. 

2.  Thermal  Stimuli. — If  a  frog's  nerve  be  heated  to  45°  C,  its 
excitability  is  first  increased  and  then  diminished.  The  higher  the 
temperature,  the  greater  is  the  excitability  and  the  shorter  is  its 
duration.  If  a  nerve  be  heated  to  50°  C.  for  a  short  time,  its 
excitability  is  abolished  as  well  as  its  conductivity.  Sudden  cooling 
of  a  nerve  to  5°  C.  acts  as  a  stimulus,  causing  contraction  in  a 
muscle. 

3.  Chemical  Stimuli. — These  excite  nerves  when  they  act  with 
a  certain  rapidity  and  thereby  alter  the  condition  of  the  nerve. 


30  TKEAT18E    OX    NERVOUS    DISEASES 

Most  chemical  stimuli  act  by  first  increasing  tlie  nervous  excita- 
bility and  then  diminishing  or  paralj-zing  it.  Chemical  stimuli^  as 
a  rule,  have  less  effect  upon  the  sensory  than  upon  the  motor  fibres. 
The  following  chemical  stimuli  excite  nerves :  alkaline  salts,  sugar, 
urea,  glycerin,  and  some  metallic  salts.  Atropine  diminishes  the 
action  of  the  pneumogastrics  and  the  glandular  nerves,  etc.  Pilo- 
carpine has  the  opposite  action.  Free  alkalies,  mineral  acids 
(not  phosphoric),  acetic,  oxalic,  tartaric,  and  lactic  acids  dimin- 
ish the  excitability  of  nerves,  as  well  as  most  salts  of  the  heavy 
metals. 

4.  Physiological  or  normal  stimuli  excite  the  nerves  in  the 
normal  body.  Its  nature  is  entirely  unknown.  The  "  nerve 
motion  "  thereby  set  up  travels  either  in  a  '"'  centrifugal '"  or  out- 
going direction  from  the  central  nervous  system,  giving  rise  to 
motion,  inhibition  of  motion,  or  secretion,  or  in  a  "  centripetal  " 
or  ingoing  motion  or  direction  from,  the  specific  end  organs  of  the 
nerves  of  the  special  senses  or  the  sensory  nerves. 

5.  Electrical  Stimuli. — The  following  forms  of  electrical  stim- 
uli may  be  used:  a.  A  constant  current,  which  may  be  made  or 
broken,  h.  Induction  shochs,  either  make  or  break  shocks,  c.  An, 
interrupted  current. 

Constant  Current. — If  the  constant  current  be  used  as  a  nerve 
stimulus,  the  stimulating  efl^ect  on  the  sensory  nerves  is  most 
marked  at  the  moment  of  making  and  breaking  the  current;  dur- 
ing the  time  the  current  passes  only  slight  excitement  is  perceived, 
but  even  under  these  circumstances  very  strong  currents  may 
cause  very  considerable,  and  even  unbearable,  sensations.  If  a 
constant  current  be  applied  to  a  motor  nerve,  the  greatest  effect 
is  produced  when  the  current  is  made  or  closed  and  when  it  is 
broken  or  opened.  But  while  the  current  is  passing,  the  stimu- 
lation does  not  cease  completely;  for,  with  a  certain  strength  of 
stimulus  the  muscle  remains  in  a  state  of  tetanus. 

An  irritation  of  sensory  nerves,  except  nervous  depressor,  pro- 
duces increase  of  blood  pressure. 

Induction  Current  or  Shocl:. — If  a  galvanic  element  is  closed 
by  means  of  a  short  arc  of  wire,  at  the  moment  the  circuit  is  again 
opened  or  broken  a  slight  spark  is  noticed.  If,  however,  the  cir- 
cuit is  made  or  closed  by  means  of  a  very  long  wire  rolled  in  a 
coil,  then,  on  breaking  the  circuit,  there  is  a  strong  spark.  If  the 
wires  be  connected  to  two  electrodes,  so  that  a  person  can  hold 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY       31 

one  in  each  hand,  the  cnrrent  at  the  moment  it  is  opened  must 
pass  through  the  person's  body — then  there  is  a  violent  shock 
communicated  to  the  hand.  This  phenomenon  is  due  to  a  current 
induced  in  the  long  spiral  of  wire  which  has  been  called  the 
extra  current. 

Interrupted  or  Faradic  Current. — If  a  very  long  insulated 
wire  be  coiled  into  the  form  of  a  spiral  roll,  which  is  called  the 
secondary  spiral,  and  if  a  similar  spiral,  the  primary  spiral,  be 
placed  near  the  former,  and  the  ends  of  the  wire  of  the  primary 
spiral  be  connected  with  the  poles  o£  a  constant  battery,  every 
time  the  current  in  the  primary  circuit  is  made  (closed),  or  broken 
(opened),  a  current  takes  place,  or,  as  it  is  said,  is  induced,  in  the 
secondary  spiral.  If  the  primary  circuit  be  kept  closed,  and  if  the 
secondary  spiral  be  brought  nearer  to  or  removed  farther  from  the 
spiral  (primary),  a  current  is  also  induced  in  the  secondary  spiral. 
The  current  in  the  secondary  circuit  is  called  the  Faradic  current. 
When  the  primary  circuit  is  closed,  or  when  the  two  spirals  are  ' 
brought  nearer  each  other,  the  current  in  the  secondary  spiral  has 
a  direction  opposite  to  that  in  the  primary  spiral,  while  the  cur- 
rent produced  by  opening  the  primary  circuit  or  by  removing  the 
spirals  farther  apart  has  the  same  direction  as  the  primary.  Dur- 
ing the  time  the  primary  circuit  is  closed,  or  when  both  spirals 
remain  at  the  same  distance  from  each  other,  there  is  no  current 
in  the  secondary  spiral. 

When  a  galvanic  current  is  passed  through  a  nerve,  it  is  said 
to  be  in  a  state  of  electrotonus,  because  its  irritability  is  modified. 
In  this  condition,  the  vital  properties  of  the  nerve  are  modified — 
i.e.,  its  electro-motivity,  its  excitability. 

If  a  nerve  be  so  arranged  upon  the  electrodes  that  its  trans- 
verse section  lies  on  one  and  its  longitudinal  on  the  other  elec- 
trode, then  the  galvanometer  indicates  a  strong  current.  If,  now, 
a  constant  current  be  transmitted  through  the  end  of  the  nerve 
projecting  beyond  the  electrodes,  and  if  the  direction  of  the  cur- 
rent coincides  with  that  in  the  nerve,  then  the  magnetic  needle 
gives  a  greater  deflection,  indicating  an  increase  of  the  nerve 
current — the  positive  phase  of  electrotonus.  The  increase  is 
greater  the  longer  the  stretch  of  nerve  traversed  by  the  current, 
the  stronger  the  galvanic  current,  and  the  less  the  distance  be- 
tween the  part  of  the  nerve  traversed  by  the  constant  current  and 
that  on  the  electrodeSo 


33  TEEATlSE    ON    NERVOUS    DISEASES 

If  in  the  same  length  of  nerve  the  constant  current  passes  in 
the  opposite  direction  to  the  nerve  current,  there  is  a  diminution 
of  the  electro-motive  force  of  the  latter — negative  phase  of  elec- 
trotonus. 

If  two  points  of  the  nerve  equidistant  from  the  equator  be 
placed  on  the  electrodes,  there  is  no  deflection  of  the  galvanometer 
needle.  If  a  constant  current  be  passed  through  one  free  pro- 
jecting end  of  the  nerve,  then  the  galvanometer  indicates  an  elec- 
tro-motive efEect  in  the  same  direction  as  the  current  (constant). 

These  experiments  show  that  a  constant  current  causes  a 
change  of  the  electro-motive  force  of  the  part  of  the  nerve  in- 
directly traversed  by  the  constant  current — i.  e.,  in  the  intra- 
polar  area — and  also  in  the  part  of  the  nerve  outside  the  elec- 
trodes— i.  e.,  in  the  extrapolar  area.  This  condition  is  called 
electrotoniis. 

Muscle  Current  during  Electrotonus. — The  constant  current 
also  produces  an  electrotonic  condition  in  the  muscle;  a  constant 
current  in  the  same  direction  increases  the  muscle  current,  while 
one  in  an  opposite  direction  weakens  it,  but  the  action  is  rela- 
tively feeble. 

Cause  of  Electrotonus. — If  a  certain  stretch  of  a  living  nerve 
be  traversed  by  a  constant  electrical  current,  it  passes  into  a  con- 
dition of  altered  excitability  which  is  known  as  electrotonus.  This 
condition  of  altered  excitability  extends  not  only  over  the  part 
actually  traversed  by  the  current,  but  it  is  communicated  to  the 
entire  nerve.  At  the  positive  pole  or  anode  the  excitability  is 
diminished;  this  is  the  region  of  anelectrotonus.  At  the  negative 
pole  or  cathode  the  excitability  is  increased;  this  is  the  region  of 
cathelectrotonus.  The  changes  of  excitability  are  most  marked  in 
the  regions  of  the  poles  themselves. 

Transmission  of  Nervous  Impulses. — If  a  motor  nerve  be  stiniu- 
lated  at  its  central  end  (1)  a  condition  of  excitation  is  set  up, 
and  (2)  an  impulse  is  transmitted  along  the  nerve  to  the  mascle 
with  a  certain  velocity.  The  latter  depends  upon  the  former  and 
represents  the  function  of  conductivity.  According  to  Helmholtz 
the  velocity  for  a  human  motor  nerve-wave  is  about  100  feet  per 
second. 

In  the  sensory  nerves  of  man,  the  velocity  of  the  impulse  is 
probably  about  the  same  as  in  motor  nerves.  The  rates  usually 
given  are  about  150  feet  per  second. 


AXATOMY,    PHYSIOLOGY,    AND    CHEMISTRY       33 

Relay  Stations  of  Motor  and  Sensory  Fibres. — The  optic  thai- 
ami  are  the  relay  stations  of  the  sensory  tract. 

The  caudate  nuclei  are  the  relay  stations  for  the  motor  tract. 

Chemical  and  Mechanical  Properties  of  Nervous  Substance. — 
Specific  gravity  of  white  substance,  1.040;  gray  substance,  1.050. 
The  reaction  is  sometimes  slightly  alkaline  and  sometimes  slightly 
acid.  It  contains  a  varying  amount  of  water  and  solid  substances ; 
75  per  cent  water  and  25  per  cent  solid  matter  is  about  the 
average. 

Proteids. — Albumin  occurs  chiefly  in  the  axis  cylinder  and  in 
the  substance  of  the  ganglionic  cells.  Some  of  this  proteid  sub- 
stance represents  characters  not  unlike  those  of  myosin.  Dilute 
solution  of  common  salt  extracts  a  proteid  from  nervous  matter, 
which  is  precipitated  by  the  addition  of  much  water  and  also  by 
a  concentrated  solution  of  common  salt.  Potash  albumin  and  a 
glohulin-like  substance  are  also  present.  Nuclein  occurs  especially 
^in  the  gray  matter,  while  neuro-heratin,  a  body  containing  much 
sulphur  and  closely  related  to  keratin,  occurs  in  the  neuroglia. 

Fats  and  other  allied  substances  soluble  in  ether,  more  espe- 
cially in  the  white  matter : 

a.  Cerehrin,  free  from  phosphorus.  It  is  a  white  powder  com- 
posed of  spherical  soluble  granules  (in  hot  alcohol  and  ether), 
but  insoluble  in  cold  water.  When  boiled  for  a  long  time  with 
acids,  it  splits  up  into  a  left  rotatory  body  like  sugar  and  another 
unknown  product. 

h.  Lecithin  and  its  decomposition  products — giycero-phosphoric 
acid  and  oleo-phosphoric  acid. 

c.  Protagon,  which  contains  nitrogen  and  phosphorus,  is  sim- 
ilar to  cerebrin  and  lecethin  combined. 

d.  Leucin,  inosite,  etc. 

The  physical  properties  of  nerve  tissue  are  cohesion  and  elas- 
ticity. 

Physiology  of  the  Cerebellum. — Irritation  of  the  cerebellum 
will  cause  no  contractions  or  pain,  but  if  it  be  deeply  injured 
there  will  be  a  tottering  of  the  animal  called  a  cerebellar  tottering. 

If  the  cerebellum  is  entirely  removed  the  animal  will  live 
for  quite  a  time,  and  will  soon  learn  to  co-ordinate  its  movements. 
The  cerebellum  is  the  centre  of  co-ordination  of  muscular  move- 
ments. It  is  probable  that  the  co-ordinating  fibres  go  through 
the  descending  antero-lateral  tract. 


34  TliEATISE    ON    NERVOUS    DISEASES 

Irritation  of  the  cerebellum  will  not  only  cause  a  tottering 
walk,  but  also  may  cause  a  tendency  to  vomit,  on  account  of  the 
irritation  of  the  vomiting  centre  in  the  medulla.  Injury  of  the 
middle  cerebellar  peduncle  causes  a  tendency  for  the  animal  to 
go  to  one  side  {circus  movements).  It  also  brings  on  internal 
squint  on  the  same  side  and  superior  squint  on  the  opposite  side. 

Lesions  of  one  hemisphere  may  not  give  rise  to  any  symptoms; 
but  if  the  middle  lobe  is  involved,  there  is  inco-ordination  of  move- 
ments, especially  a  tendency  to  fall,  unsteady  gait,  and  pronounced 
vertigo.  Irritative  lesions  of  the  middle  peduncle  cause  complete 
gyrating  movements  of  the  body  around  its  axis,  together  with 
rotation  of  the  eyes  and  head. 

Functions  of  the  Medulla  Oblongata. — The  medulla  oblongata, 
which  connects  the  spinal  cord  with  the  brain,  has  many  points 
of  resemblance  with  the  former.  Like  the  cord,  it  is  concerned 
in  the  conduction  of  impulses.  In  it  numerous  reflex  centres  are 
present — e.  g.,  for  simple  reflexes  similar  to  the  nerve-centres  in 
the  spinal  cord.  There  are  other  centres  present  which  seem  to 
dominate  or  control  similar  centres  placed  in  the  cord — e.  g.,  the 
great  vaso-motor  centre,  pupil-dilating  centres,  and  the  centre  for 
combining  the  reflex  movements  of  the  body.  Some  of  the  centres 
are  capable  of  being  excited  reflexly.  It  is  also  said  to  contain 
automatic  centres.  The  normal  functions  of  the  centres  depend 
upon  the  exchanges  of  blood  and  gases  effected  by  the  circulation 
of  the  blood  through  the  medulla.  If  this  gaseous  exchange  be 
interrupted  or  interfered  with — as  asphyxia,  sudden  anaemia,  or 
venous  congestion — these  centres  are  first  excited,  and  exhibit  a 
condition  of  increased  excitability,  and  at  last,  if  they  are  over- 
stimulated  they  are  paralyzed.  An  excessive  temperature  also  acts 
as  a  stimulus  by  an  action  on  the  polypnoeic  centre  in  the  tuber 
cinereum  which  drives  the  respiration  centre  into  activity.  All  the 
centres,  however,  are  not  active  at  the  same  time,  and  they  do  not 
all  exhibit  the  same  degree  of  excitability.  Normally,  the  respira- 
tory centre  and  the  vaso-motor  centre  are  continually  in  a  state 
of  activity. 

The  centres  found  in  the  medulla  have  been  given  under  the 
anatomy  of  same. 

The  respiratory  centre  lies  in  the  m.edulla  behind  the  super- 
ficial origin  of  the  vagus,  on  both  sides  of  the  posterior  aspect 
of  the  apex  of  the  calamus  scriptorius,  between  the  nuclei  of  the 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY^      35 

vagus  and  accessorius.  It  consists  of  two  parts,  which  are  in  a 
state  of  activity  alternately,  an  inspiratory  and  an  expiratory:, 
each  one  forming  the  motor  central  point  for  the  acts  of  inspira- 
tion and  expiration.  Some  observers  claim  that  this  is  an  auto- 
matic centre,  for  after  section  of  all  the  sensory  nerves  which 
can  act  refiexly  upon  the  centre,  it  still  retains  its  activity.  The 
degree  of  excitability  and  the  stimulation  of  the  centre  depend 
upon  the  state  of  the  blood,  and  chiefly  upon  the  amount  of 
blood  gases. 

The  Cardio-inhibitory  Centre. — The  fibres  of  the  vagus,  when 
moderately  .stimulated,  diminish  the  action  of  the  heart;  when 
strongly  stimulated,  however,  they  arrest  its  action  and  cause  it 
to  stand  still  in  diastole;  they  are  supplied  to  the  vagus  through 
the  spinal  accessory  nerve,  and  have  their  centre  in  the  medulla 
oblongata.  Gaskell  has  shown  that  stimulation  of  the  vagus  not 
only  influences  the  rhythm  of  the  heart's  action,  but  modifies  the 
other  functions  of  the  cardiac  muscle.  Stimulation  of  the  vagus 
influences  the  automatic  rhythm — i.  e.,  the  rate  at  which  the  heart 
contracts  automatically;  the  force  of  the  contractions,  more  espe- 
cially the  auricles,  although  in  some  animals — e.  g.,  the  tortoise — 
the  ventricles  are  not  affected ;  the  power  of  conduction — i.  e.,  the 
capacity  for  conducting  the  muscular  contractions.  This  centre 
may  be  excited  directly  in  the  medulla,  and  also  reflexly  by  stimu- 
lating certain  efferent  nerves.  Stimulation  of  the  trunk  of  the 
vagus  from  the  centre  downward,  along  its  whole  course,  and  also 
of  certain  of  its  cardiac  branches,  causes  the  heart  either  to  beat 
more  slowly  or  arrests  its  action  in  diastole.  The  result  depends 
upon  the  strength  of  the  stimulus  employed;  feeble  stimuli  slow 
the  action  of  the  heart,  while  strong  stimuli  arrest  it  in  diastole. 

Cardiac- Accelerating  Centre. — This  centre  is  also  located  in  the 
medulla  oblongata,  which  sends  accelerating  fibres  to  the  heart. 
They  pass  from  the  medulla  through  the  spinal  cord,  and  leave 
the  cord  through  the  rami  communicantes  of  the  lower  cervical 
and  upper  six  dorsal  nerves  to  pass  into  the  sympathetic  system. 
If  the  vagi  of  an  animal  be  divided,  stimulation  of  the  medulla 
oblongata,  of  the  lower  end  of  the  divided  cervical  spinal  cord, 
even  of  the  lower  cervical  ganglion,  or  of  the  upper  dorsal  gan- 
glion of  the  sympathetic,  causes  acceleration  of  the  heart-beats  in 
the  dog  and  rabbit  without  the  blood-pressure  undergoing  any 
change.     The  inhibitory  fibres  of  the  vagus  lose  their  excitability 


36  TREATISE    ON"    NEEVOUS    DISEASES 

more  readily  than  the  accelerating"  fibres^  but  the  vagus  fibres  are 
more  excitable  than  those  of  the  accelerans. 

Vaso-motor  Centre  and  Nerves. — The  chief  dominating  centre, 
which  supplies  all  the  non-striped  muscles  of  the  arterial  system 
with  motor  nerves,  lies  in  the  medulla  oblongata  at  a  point  which 
contains  ganglionic  cells.  The  nerves  passing  from  this  centre  are 
known  as  the  vaso-motor  nerves,  there  being  two  kinds  of  them — 
vaso-constricior  and  vaso-dilator.  The  vaso-constrictor  nerves, 
as  their  name  implies,  constrict  the  arteries,  or  rather  reduce  their 
mean  diameters,  thus  causing  an  increase  of  blood-pressure,  result- 
ing in  the  swelling  of  veins  and  the  heart.  The  vaso-dilator  nerves, 
as  their  name  implies,  cause  a  dilatation  of  the  arteries  and  a  de- 
crease in  blood-pressure. 

Functions  of  the  Pons  Varolii. — This  is  seated  in  front  of  the 
medulla,  and  is  the  centre  of  convulsive  movements.  In  epi- 
lepsy there  is  a  lesion  of  the  cortex  of  the  brain,  and  the  im- 
pressions are  conveyed  to  the  convulsive  centre.  It  is  also  a  path 
for  the  conduction  of  sensibility  and  motion.  If  there  is  a  lesion 
in  the  pons,  there  is  a  paralysis  of  the  face  on  one  side  and  of 
the  leg  and  arm  of  the  opposite  side.  This  is  due  to  a  lesion  helow 
the  facial  decussation  and  above  the  motor  decussation  of  the 
fibres  in  the  pons.  The  convulsion  centre  can  be  excited  by  ex- 
cess of  carbonic  acid,  lack  of  oxygen,  anaemia,  etc. 

Functions  of  Cerebral  Peduncles. — They  are  about  f  of  an  inch 
in  length,  and  contain  fibres  which  connect  the  brain  with  the 
structures  at  its  base.  In  the  locus  niger  there  is  located  the 
high  detrusor  centre  of  the  bladder,  although  the  proper  detrusor 
centre  is  located  down  in  the  cord. 

Injury  to  one  cerebral  peduncle  causes,  in  the  first  place,  violent 
pain  and  spasm  of  the  opposite  side,  while  the  blood-vessels  on 
that  side  contract  and  the  salivary  glands  secrete.  These  phenom- 
ena of  irritation  are  followed  by  paralytic  symptoms  of  the  oppo- 
site side — viz.,  anaesthesia  and  paresis.  In  afl:ections  of  the  cerebral 
peduncle  in  man,  we  must  remember  the  relation  of  the  oculomo- 
torius  to  it,  as  the  latter  is  often  paralyzed  on  the  same  side,  while 
the  extremities,  tongue,  and  half  the  face  are  paralyzed  on  the 
opposite  side  from  the  lesion. 

Functions  of  the  Corpora  Cluadrigemina. — Destruction  of  these 
bodies  on  one  side  in  mammals  causes  actual  blindness,  which 
may  be  on  the  same  or  the  opposite  side,  according  to  the  relation 


ANATOMY,    PHYSIOLOGY,    AI^D    CHEMISTEY       37 

of  the  fibres  crossing  at  the  optic  chiasm.  Total  destruction  causes 
blindness  of  both  eyes.  At  the  same  time,  the  reflex  contraction 
of  the  pupil,  due  to  the  stimulation  of  the  retina  with  light,  no 
longer  takes  place  where  the  optic  is  the  afferent  and  the  oculo- 
motorius  the  efferent  nerve.  If  the  cerebral  peduncles  are  left  in 
position  and  the  cerebral  hemisphere  alone  be  removed,  the  pupil 
still-  contracts  to  light,  as  well  as  after  mechanical  stimulation  of 
the  optic  nerve.  Destruction  of  the  corpora  quadrigemina  inter- 
feres with  the  complete  harmony  of  the  motor  acts;  disturbance 
of  equilibrium  and  inco-ordination  of  movements  occur. 

In  man  very  little  is  known  regarding  the  effects  of  disease 
of  the  corpora  quadrigemina,  interference  with  the  ocular  mus- 
cles being  the  most  marked  symptom;  but  the  inco-ordination  of 
movement  which  has  been  observed  may  be  due  to  pressure  upon 
the  superior  cerebellar  peduncle,  while  it  is  by  no  means  certain 
that  the  defects  of  vision  are  directly  due  to  lesions  of  these 
bodies. 

Forced  Movements. — It  is  evident  from  what  has  been  said 
regarding  the  importance  of  the  corpora  quadrigemina  for  the 
harmonious  execution  of  movements,  that  unilateral  injury  of  such 
parts  as  are  connected  with  them  by  conducting  channels  must 
give  rise  to  peculiar  unilateral  disturbance  of  the  equilibrium, 
causing  variations  from  the  symmetrical  movements  of  both  sides 
of  the  body.     These  are  called  "  forced  movements." 

Strabismus  and  Nystagmus. — Among  the  forced  movements 
may  be  reckoned  deviation  of  the  eyeballs,  strabismus  or  squinting, 
and  involuntary  oscillation  of  the  eyeballs,  constituting  nystagmus. 
The  latter  condition  occurs  after  superficial  lesions  of  the  resti- 
form  bodies,  as  well  as  of  the  floor  of  the  fourth  ventricle. 

■Contraction  centre  of  iris  is  in  the  anterior  corpora  quadri- 
gemina. 

Functions  of  the  Corpora  Striata, — Lenticular  and  Caudate  Nu- 
clei.— Electrical  stimulation  of  these  nuclei  causes  general  con- 
tractions in  the  opposite  half  of  the  body  which  are  due  to  simul- 
taneous stimulation  of  the  neighbouring  cortico-muscular  paths. 
There  is  no  sign  of  pain.  Lesions  of  the  lenticular  nucleus  or  of 
the  caudate  nucleus  do  not  seem  to  give  rise  to  any  permanent 
symptoms,  provided  the  internal  capsule  is  not  injured.  If  the 
corpus  striatum  is  destroyed  on  one  side,  there  is  paralysis  of  the 
opposite  side  of  the  body.     This  body  holds  the  same  relation  to 


38  TEEATISE    OX    NERVOUS    DISEASES 

the  motor  tract  that  the  optic  thalami  bear  to  the  sensory  tracts; 
on  the  other  hand,  or  in  other  words,  the  corpora  striata  are  the 
relay  stations  of  the  motor  tracts.  These  bodies  also  contain  a 
thermogenic  centre,  and  if  section  is  made  of  both  the  temperature 
will  rise  to  110.5°  F.  If  section  be  made  of  the  tuher  cinereum 
there  will  be  a  great  increase  of  temperature. 

Functions  of  Optic  Thalami. — Ferrier  did  not  observe  any 
movements  on  stimulating  the  optic  thalami  with  electricity.  As 
the  puhinar  or  the  posterior  extremity  of  the  optic  thalamus  is  in 
part  the  origin  of  the  optic  nerve,  and  is  also  connected  by  fibres 
with  the  cerebral  cortex,  it  is  probably  related  to  the  sense  of 
sight.  Injury  to  its  posterior  third  in  man  results  in  disturbance 
of  vision.  Ferrier  surmises  that  the  sensory  fibres  pass  through 
the  optic  thalami  on  their  way  to  the  cortex,  so  that  M^hen  they 
are  destroyed  insensibility  of  the  opposite  half  of  the  body  is 
produced.  Thus  these  bodies  are  called  relay  stations  for  the 
sensory  tracts. 

The  Capsules:  Functions,  Etc. — In  connection  with  the  func- 
tions of  the  basal  ganglia  it  is  most  important  to  remember  their 
relation  to  the  internal  capsule.  The  anterior  segment  of  the 
internal  capsule  sweeps  between  the  caudate  and  lenticular  nuclei, 
while  the  posterior  segment  lies  between  the  optic  thalamus  and  the 
lenticular  nucleus.  External  to  the  first  division  of  the  lenticular 
nucleus  is  the  external  capsule,  whose  function  is  unknown.  Ex- 
ternal to  this  latter  structure  is  the  claustrum,  whose  function 
also  is  unknown.  It  is  evident  that  hsemorrhage  into  or  about  the 
basal  ganglia  is  apt  to  involve  the  fibres  of  the  internal  capsule. 
When  the  "  artery  of  hsemorrhage "  ruptures  it  may  not  only 
destroy  the  lenticular  nucleus,  but  the  internal  capsule  will  be 
compressed,  and  the  same  is  the  ease  with  the  I enticulo -thalamic 
artery — the  external  capsule  will  tend  to  force  the  blood  inward. 
We  know  that  in  the  posterior  segment  of  the  capsule  the  voli- 
tional or  pyramidal  fibres  lie  in  the  following  order  from  before 
backward:  those  for  the  face  (and  tongue)  in  the  knee;  in  the 
anterior  third,  those  for  the  arm  and  hand;  and  in  the  middle 
third,  for  the  leg,  and  perhaps  behind  these  those  for  the  trunk; 
so  that  a  very  small  lesion  in  this  region  will  affect  a  large  num- 
ber of  these  fibres,  converging  as  they  do  like  the  rays  of  a  fan 
from  the  motor  cortical  areas,  where  the  arrangement  of  these 
centres  is  a  supero-inferior  one,  to  become  an  antero-posterior  one 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTEY       39 

in  the  knee  and  posterior  limb  of  the  internal  capsule.  The- pos- 
terior third  of  this  limb  is  sensory,  and  is  the  sensory  cross-way. 

Destruction  of  the  internal  capsule  causes  paralysis  of  motion 
or  sensibility,  or  both,  on  the  opposite  side  of  the  body,  according 
to  the  part  of  it  which  is  injured. 

Functions  of  Cerebral  Hemispheres. — The  cortical  motor  areas 
for  the  face,  arm,  and  leg  are  grouped  around  the  fissure  of  Ro- 
lando, including  the  ascending  frontal,  ascending  parietal,  and 
paracentral  lobules.  The  centre  for  the  face  occupies  the  lowest 
third  of  the  ascending  frontal  convolution,  and  reaches  also  to 
the  lowest  fifth  of  the  ascending  parietal.  The  arm  centre  occu- 
pies the  middle  third  of  the  ascending  frontal  and  middle  three- 
fifths  of  the  ascending  parietal  convolutions,  while  the  leg  centres 
lie  at  the  upper  end  of  the  sulcus  and  extends  backward  into  the 
parietal  lobule.  The  leg  centre  is  continued  over  on  to  the  para- 
central lobule,  opposite  the  upper  end  of  the  fissure  of  Eolando, 
i]i  the  marginal  convolution  on  the  mesial  aspect  of  the  hemi- 
sphere, where  the  centres  for  the  muscles  of  the  trunk  also  exist. 
The  motor  areas  are  supplied  by  branches  of  the  Sylvian  artery. 

To  locate  the  fissure  of  Rolando  on  the  cranium,  a  line  is 
drawn  from  the  glabella  to  the  external  occipital  protuberance. 
Divide  the  distance  into  two  equal  parts,  and  ^  an  inch  behind 
the  middle  point  is  the  top  of  the  fissure  of  Eolando. 

The  cortical  sensory  areas  are  distributed  very  irregularly. 
There  must  be  some  connection  between  the  surface  of  the  brain 
and  the  afl:erent  channels  through  which  sensory  impulses  pass 
inward;  and  although  the  channels  for  these  impulses  are,  perhaps, 
not  so  well  known,  it  must  be  that  sensory  impulses  fgr  the  opposite 
half  of  the  body  travel  upward  through  the  posterior  third  of  the 
posterior  limb  of  the  internal  capsule,  to  radiate  in  all  probability 
into  the  occipital,  temporal,  and  parietal  lobes.  Parts  of  these 
different  convolutions  are  sometimes  spoken  of  as  sensory  centres. 

Extirpation  and  stimulation  are  the  methods  employed  to  de- 
termine the  different  areas  on  the  brain. 

Hemiplegia  consists  of  motor  paralj^sis  of  one-half  of  the  body, 
although,  as  a  rule,  all  tlie  muscles  are  not  paralyzed  to  the  same 
extent;  in  some  there  may  be  complete  paralysis — i.  e.,  they  are 
entirely  removed  from  voluntary  control — while  in  others  there 
is  merely  impaired  voluntary  control.  It  may  be  caused  by  affec- 
tions of  the  cortical  areas  or  by  lesion  of  the  motor  tracts  above 


40      TREATISE  ON  NEEYOUS  DISEASES 

the  medulla ;  and  the  paralysis  is  alwaj^s  on  the  side  opposite  to  the 
lesion,  owing  to  the  decussation  of  the  motor  paths  in  the  medulla. 
If  the  case  be  a  severe  one,  there  is  a  complete  hemiplegia  due  to 
lesion  of  the  cortical  centres  for  the  face,  arm,  and  leg.  While 
the  arm  and  leg  are  completely  paralyzed,  the  lower  part  of  the 
face  is  more  affected  than  the  upper  half,  which  is  usually  not 
affected.     The  arm  recovers  more  quickly  than  the  leg. 

Conjugate  deviation  of  the  eyes,  with  rotation  of  the  head, 
is  frequently  present  in  the  early  period  of  hemiplegia,  although 
it  usually  disappears.  When  a  person  turns  his  head  to  one  side 
there  is  an  associated  movement  of  certain  of  the  ocular  muscles 
with  those  of  the  neck.  The  head  and  eyes  are  usually  turned  to 
the  side  of  lesion;  this  is  termed  conjugate  deviation,  so  that 
the  power  of  voluntarily  moving  the  eyes  and  head  to  the  para- 
lyzed side  is  temporarily  lost.  The  unopposed  muscles  rotate  the 
head  and  eyes  to  the  sound  side.  If  a  lesion  be  in  the  posterior 
part  of  the  pons,  the  deviation  is  to  the  paralyzed  side. 

Irritation  of  the  Motor  Centres. — If  the  motor  centres  are  irri- 
tated by  pathological  processes,  such  as  hypersemia,  inflammation 
in  a  syphilitic  diathesis,  tumours,  tubercles,  cj^sts,  fragments  of 
bone,  etc.,  there  arise  spasmodic  movements  in  the  corresponding 
muscle  groups.  This  condition  of  a  sudden  discharge  of  the  gray 
matter  resulting  in  local  spasms  is  called  Jachsonian  cerebral 
epilepsy. 

The  Centre  of  Speech. — The  investigations  of  Broca  and  others 
liave  shown  that  tlie  third  left  frontal  convolution  of  the  cerebrum 
(Broca's  area)  is  of  essential  -importance  for  speech,  while  prob- 
ably the  island  of  Eeil  is  also  concerned. 

Three  activities  are  required  for  speech:  (1)  the  normal  move- 
ment of  the  vocal  apparatus;  (3)  a  knowledge  of  the  signs  for 
objects  and  ideas;  (3)  the  correct  union  of  both. 

Aphasia. — Injury  of  the  speech  centre  causes  either  a  loss  or 
more  or  less  considerable  disturbance  of  the  power  of  speech.  The 
loss  of  the  power  of  speech  is  called  aphasia.  Aphasia,  as  usu- 
ally understood,  means  the  partial  or  complete  loss  of  the  power 
of  articulate  speech  from  cerebral  causes.  A  person  may  compre- 
hend what  he  sees  or  hears,  yet  he  is  imable  to  speak. 

Ataxic  Aphasia. — Here  there  is  loss  of  speech  owing  to  inability 
to  execute  the  various  movements  of  the  mouth  necessary  for  speech 
and  co-ordinated  grimaces.     He  can  utter  inarticulate  words  or 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTEY       41 

sounds.  The  muscles  concerned  in  articulation  are  not  paralyzed, 
but  there  is  an  absence  of  co-ordination  of  these  muscles  due  to  dis- 
ease of  the  cortical  centre.  Hence  the  patient  cannot  repeat  what 
is  said  to  him.  Nevertheless,  the  psychical  processes  necessary  for 
speech  are  completely  retained,  and  all  words  are  remembered ;  and 
hence  these  persons  can  still  give  expression  to  their  thoughts 
graphically  by  writing.  If,  however,  the  finely  adjusted  movements 
necessary  for  writing  are  lost,  owing  to  an  affection  of  the  centre 
for  the  hand,  then  there  arises  at  the  same  time  the  condition  of 
agraphia,  or  inability  to  execute  those  movements  necessary  for 
writing.  Such  a  person,  when  he  desires  to  express  his  ideas  in 
writing,  only  succeeds  in  making  a  few  unintelligible  scrawls  on 
the  paper. 

In  ivord  blindness,  the  person  cannot  name  a  letter  or  a  word, 
so  that  he  cannot  understand  symbols,  such  as  printed  or  written 
words,  or  it  may  be  a  familiar  object ;  although  he  can  see  quite 
well,  while  he  can  speak  fluently  and  write  correctly. 

In  wo7'd  deafness,  the  person  hears  other  sounds  and  is  not  deaf, 
but  he  does  not  hear  and  understand  words.     (See  Aphasia.) 

An  animal  or  person  can  live  with  only  one  cerebral  hemisphere 
intact;  but  if  both  are  removed,  the  animal  lies  still,  remaining 
in  one  position,  and  will  not  move. 

Seats  or  centres  of  consciousness  and  volition  (ivill)  are  lo- 
cated in  the  cerebral  cortex. 

The  cerebrum  contains  the  centres  of  intelligence.  There  are 
many  ways  of  measuring  the  grade  of  intelligence  of  a  man;  the 
important  is  the  facial  angle  measurement,  explained  as  follows: 
The  facial  angle  (Camper)  is  the  divergence  between  a  line  drawn 
from  the  inferior  anterior  nasal  ridge  of  upper  jaw  to  the  gla- 
bella, and  another  drawn  from  the  nasal  ridge  to  the  external  audi- 
tory meatus.  In  the  Caucasian  race  it  is  80° ;  in  the  Mongolian, 
75°;  in  the  Ethiopian,  70°;  and  in  apes,  40°. 

The  Visual  Centre. — According  to  Munk,  this  includes  the 
occipital  lobes  (cuneus),  while,  according  to  Ferrier,  it  also  in- 
cludes the  angular  gyrus.  In  cases  of  long-standing  blindness 
there  has  been  noticed  to  be  a  consecutive  disappearance  of  the 
occipital  convolutions  on  both  sides  of  the  parieto-occipital  fis- 
sure. Stimulation  of  the  centre  gives  rise  to  the  phenomena  of 
light  and  colour.  Injury  causes  a  disturbance  of  vision,  especially 
hemiopia  of  the  same  side,  to  be  further  explained  under  the  eye. 


42  TEEATISE    0^    NERVOUS    DISEASES 

When  one  centre  is  the  seat  of  irritation,  there  is  a  photopsia-  of 
the  same  halves  of  both  eyes.  Stimulation  of  both  centres  causes 
the  occurrence  of  the  phenomena  of  light  or  colour  or  visual 
hallucinations  in  the  entire  field  of  vision. 

The  auditory  centres  are  found  in  the  superior  temporal  con- 
volutions. When  this  is  completely  removed,  deafness  is  the  re- 
sult, while  partial  injury  causes  psychical  deafness.  It  has  been 
found  that  softening  of  the  first  temporal  convolution  is  the  cause 
of  these  phenomena. 

The  centres  of  taste  and  smell  are  located  in  the  gyrus  unci- 
natus. 

The  centre  of  tactile  sensibility  is  located  in  the  gyrus  forni- 
catus,  according  to  some  observers;  by  others,  in  the  motor  area. 

Sleep  and  Waking. — In  sleep  and  waking  we  observe  the  peri- 
odicity of  the  active  and  passive  conditions  of  the  brain.  During 
sleep  there  is  diminished  excitability  of  the  whole  nervous  system, 
which  in  turn  is  partly  due  to  fatigue  of  the  afferent  nerves,  though 
largely  due  to  the  condition  of  the  central  nervous  system.  During 
sleep  we  require  to  apply  strong  stimuli  to  produce  reflex  acts. 
In  the  deepest  sleep  the  mental  processes  seem  to  be  completely 
in  abeyance,  so  that  a  person  asleep  might  be  compared  to  an  ani- 
mal with  its  cerebral  hemispheres  removed.  Towards  the  approach 
of  the  period  when  a  person  is  about  to  waken,  psychical  activity 
may  manifest  itself  in  the  form  of  dreams,  which  differ,  however, 
from  normal  mental  processes.  They  consist  either  of  impressions, 
where  there  is  no  objective  cause,  or  of  voluntary  impulses  which 
are  not  executed,  or  trains  of  thought  where  the  reasoning  and 
judging  powers  are  disturbed.  Often,  especially  near  the  time 
of  waking,  the  actual  stimuli  may  so  act  as  to  give  rise  to  im- 
pressions which  become  mixed  with  the  thoughts  of  a  dream. 
The  pupils  are  contracted  during  sleep  in  proportion  to  its  depth ; 
so  that  in  the  deepest  sleep  they  do  not  become  contracted  on 
the  application  of  light.  The  pupils  dilate  when  sensory  or  audi- 
tory stimuli  are  applied,  and  the  lighter  the  sleep  the  more  easily 
is  it  accomplished — they  are  the  widest  at  the  moment  of  awaking. 

The  soundness  of  sleep  may  be  determined  by  the  intensity  of 
the  sound  required  to  awaken  a  person.  Some  observers  find  that 
at  first  sleep  deepens  very  quickly,  then  more  slowly,  and  the 
maximum  is  reached  after  one  hour ;  it  then  rapidly  lightens,  until 
several  hours  before  waking  it  is  very  light.     We  therefore  sleep 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTEY       43 

soundest  the  first  two  hours,  and  weakest  towards  morning.  Tlie 
deei^er  the  sleep  tlie  longer  it  lasts. 

The  cause  of  sleep  is  the  using  up  of  the  potential  energy, 
especially  in  the  central  nervous  system,  which  renders  a  restitu- 
tion of  energy  necessary.  Perhaps  the  accumulation  of  the  decom- 
position products  of  the  nervous  activity  may  also  act  as  a  sleep- 
producer.  Sleep  cannot  be  kept  up  for  above  a  certain  time,  nor 
can  it  be  interrupted  voluntarily.  Many  narcotics  rapidly  pro- 
duce sleep.  Hypnotics,  such  as  opium,  morphine,  potassium  bro- 
mide, and  chloral,  are  drugs  which  induce  sleep. 

Strength  and  Liminal  Intensity  of  Stimuli. — Homologous  stim- 
uli act  upon  the  sensory  organs  only  within  certain  limits  as  to 
strength.  Very  feeble  stimuli  at  first  produce  no  effect.  The 
strength  of  stimulus  which  is  just  sufficient  to  cause  the  first  trace 
of  sensation  is  called  by  Fechner  the  "  liminal  intensity  "  of  the 
sensation.  As  the  strength  of  the  stimulus  increases,  so  also  do  the 
sensations,  but  the  sensations  equally  increase  when  the  strength 
of  the  stimulus  increases  in  relative  proportions.  Thus,  we  have 
the  same  sensation  of  equal  increase  of  light  when,  instead  of  10 
candles  11,  or  instead  of  100  candles  110  are  lighted — the  pro- 
portion of  increase  in  both  cases  is  equal  to  one-tenth.  As  the 
logarithm  of  the  numbers  increases  in  an  equal  degree  when  the 
numbers  increase  in  the  same  relative  proportion,  the  law  may  be 
expressed  thus :  "  The  sensations  do  not  increase  with  the  absolute 
strength  of  the  stimuli,  but  nearly  as  the  logarithm  of  the  strength 
of  the  stimulus."  This  is  Fechner's  "  psycho-physical  law,"  but 
its  accuracy  has  lately  been  challenged  by  Hering.  It  holds  good 
only  with  regard  to  stimuli  of  medium  strength.  If  the  specific 
stimulus  be  too  intense,  it  gives  rise  to  peculiar  painful  sensations 
— e.  g.,  a  feeling  of  blindness  or  deafness,  as  the  case  may  be. 
The  sense  organs  respond  to  adequate  stimuli,  but  only  with  cer- 
tain limits  of  the  stimulus — e.  g.,  the  ear  responds  only  to  vibra- 
ting bodies,  emitting  a  certain  range  of  vibrations  per  second; 
the  retina  responds  only  to  vibrations  of  the  ether  between  red 
and  violet,  but  not  to  the  so-called  heat  vibrations  or  to  the 
chemically  active  vibrations.  It  was  Weber  who  worked  out  the 
relation  between  the  intensity  of  stimuli  and  the  changes  in  the 
quantity  of  the  resulting  sensations.  He  used  the  method  of 
"  least  observable  differences,"  as  applied  to  sensations  of  pressure 
and  the  measurements  of  lines  by  the  eye.     Hence  it  is  called 


CORTEX. 


OPTIC  THALAMUS. 


HORIZONTAL 

SECTION  OF 

CRUS. 


HORIZONTAL 
SECTION  OF 
SPINAL  CORD 


ANTERO-LATERAL 
-     ASCENDING 
TRACT. 


DIRECT 

CEREBELLAR 

COLUMN. 


SENSORY  BRANCH 
TO   MOTOR  CELL 
IN  ANTERIOR 
HORN. 


GANGLION  OF 

POSTERIOR  (SEN 

SORY)  ROOT. 


■  DENDRITES 


Each  cell  of  the  ganglia  of 
the  posterior  roots  of  the  spi- 
nal cord  (or  of  the  cranial 
nerve  nuclei)  gives  off  two 
main  processes.  One,  the  den- 
drite, goes  to  the  sensory  end 
organ  in  the  skin  or  elsewhere, 
bringing  impressions  to  the 
cell,  and  constituting  the  pe- 
ripheral sensory  nerve-fibre; 
the  other,  the  axone,  enters 
the  cord  through  the  poste- 
rior root  (or  runs  from  the  cra- 
nial nerve  nuclei  inward),  com- 
ing into  relation  with  other 
neurones. 


BLUE"  =  DIRECT  SETvlSORY  PATHWAY. 
RED  =  INDIRECT  SENSORY  PATHWAY, 


Pig.  7.— Sensory  Pathways.  The  direct  sensorij  path  (in  blue)  (for  touch,  pain,  and 
temperature)  runs  f lom  posterior  root  across  the  cord  to  antero-lateral  column,  to 
tegmentum  of  crus,  to  optic  thalamus,  to  cortex.  The  indirect  senwry  2Jaths{in 
red)  (for  co-ordinative  sensations  from  muscles,  joints,  and  viscera)  run  upward  on 
same  side,  via  the  direct  cerebellar  tract  and  the  posterior  column,  decussating  at 
UDDer  iiart  of  cord,  to  cereliellum.  to  ontic  thalamus,  to  cortex.     (From  Butler.) 


HORIZONTAL  SECTION 

OF  THE  LEFT 

INTERNAL 

CAPSULE 


VERTICAL  SECTION 
OF  INTERNAL 
CAPSULE. 


HORIZONTAL  SEC- 
TION OF  CRUS. 


CEREBELLUM  AND 

INDIRECT  MOTOR 

PATHWAY. 


MOTOR  DECUSSATION 
N   MEDULLA. 


HORIZONTAL 

SECTION  OF 

THE  SPINAL 

CORD. 


DIRECT  PYRAM< 
IDAL  TRACT. 


ANTERIOR  ROOT 

OF  SPINAL         i  L 
NERVE.        O' 


ANTERIOR  ROOT 

OF  SPINAL 

NERVE. 


BLACK  FIBRES  =  INDIRECT  PATHV\/AY. 


'■J[. 


BUJt^  PtRIPHeRAL  ;Luv 
RED  =  CENTRAL  fUPPER)  NEURONE 
FiQ  8. — Motor  Pathways.  Direct  motor  path  (in  red)  (for  voluntary  impulses, 
runs  from  cortex,  via  corona  radiata,  internal  capsule,  crus,  pons,  medulla,  crossed 
and  direct  pyramidal  columns,  to  motor  cells  of  anterior  horn ;  the  cranial  nerve 
motor  fibres"  (in  red)  cross  at  various  levels  in  crus,  pons,  and  medulla.  Indirect 
motor  path  (in  black)  (for  muscul:.  co-ordination  and  higher  reflex  and  automatic 
movements)  runs  from  cortex  to  pons  nuclei,  to  cerebellum,  to  lateral  fundamental 
column,  via  the  peduncles,  the  fibres  terminating  at  various  levels  in  the  anterior 
horn.     (From  Butler.) 

45 


46  TEEATISE    ON    NERVOUS    DISEASES 

Weber's  law;  but  Fechner  expanded  it,  and  assumed  that  all  Just 
observable  differences  are  equally  great,  and  so  the  law  is  some- 
times called  by  his  name.  Generally  speaking,  it  is  called  Weher- 
Fechners  law. 

After-Sensations. — The  term  "after-sensation"  is  applied  to 
the  following  phenomenon :  viz.,  that,  as  a  rule,  the  sensation  lasts 
longer  than  the  stimulus  producing  it;  thus  there  is  an  after- 
sensation  after  pressure  is  applied  to  the  skin.  Subjective  sensa- 
tions occur  when  stimuli  due  to  internal  somatic  causes  excite  the 
nervous  apparatus  of  the  sense  organ.  The  highest  degrees  of 
these,  depending  mostly  upon  pathological  stimulation  of  the  sen- 
sory cortical  centres,  are  characterized  as  hallucinations — e.  g., 
when  a  delirious  person  imagines  he  sees  figures  or  hears  sounds 
which  have  no  objective  reality.  In  opposition  to  this  condition, 
the  term  illusion  is  applied  to  modifications  by  the  sensorium  of 
sensations  actually  caused  by  external  objects — e.  g.,  when  the 
rolling  of  a  wagon  is  mistaken  for  thunder,  etc.  In  other  words, 
an  illusion  is'  the  misinterpretation  of  an  objective  stimulation. 

Ideation  is  the  forination  of  ideas  caused  by  cerebral  activity. 

The  Sympathetic  Nervous  System:  Function,  Etc. — It  consists 
of  a  double  chain  of  ganglia  on  each  side  of  the  spinal  column  and 
visceral  plexuses.  It  is  chiefly  composed  of  non-medullated  nerve- 
fibres.  Its  chief  function  is  vaso-motor.  Its  ganglia  are  readily 
paralyzed  by  nicotine. 

OTHER    NON-NERVOUS    TISSUES 

Blood-Vessels. — The  nerves  are  richly  supplied  with  blood. 
The  peripheral  nerves  also  are  supplied  from  different  arterial 
branches,  but  always  from  one  general  source.  The  artery  passes 
to  the  nerve-sheath  obliquely,  then  divides  dichotomously,  -send- 
ing branches  for  a  long  distance  up  and  domi  the  sheath.  It 
may  pierce  the  sheath  first,  however,  then  divide  as  above  de- 
scribed. The  dichotomous  branches  send  off  arterioles  and  capil- 
laries which  form  plexuses  about  the  nerve  fascicles,  the  so- 
called  "interfascicular  arcades."  This  division  of  the  arteries 
subserves  the  function  of  preventing  large  and  sudden  impact  of 
blood  into  the  parenchyma  of  the  nerves.  This  resembles  also 
the  brain  and  cord  distribution  of  the  blood. 

The  veins  subdivide  dichotomously  like  the  arteries,  and  freely 


ANATOMY,    PHYSIOLOGY,    AND    CHEMISTEY      47 

anastomose  with  the  veins  of  the  muscles,  so  that  muscular  action 
is  in  close  sympathy  with  nerve  function  and  circulation.  Veins 
of  superficial  nerves  thus  also  connect  with  the  deep  nerve  veins. 

Lymphatic  vessels  and  spaces  are  found  in  the  epineurium  and 
perineiirium.  There  are  no  demonstrable  lymphatic  vessels  in  the 
fasciculi  of  nerves,  but  lymph  spaces  probably  exist. 

Neuroglia. — In  addition  to  connective  tissue,  the  central  nerv- 
ous system  has  another  substance  not  found  in  the  peripheral 


Fig.  9. — Showing  the  relation  of  the-  spinal  cord  to  the  dorsal  surface  of  the  trank 
the  relative  length  of  the  cervical,  dorsal,  lumbar,  and  sacral  portions;  and  the 
position  of  the  cervical  and  lumbar  enlargements. 


nervous  system.  It  is  called  the  neuroglia  and  is  derived  from 
the  epiblast.  Its  cells  are  very  numerous  and  are  finely  ramified 
together,  in  the  which  they  support  the  nerve-cells.  They  are  also 
called  "  spider  cells "  and  consist  of  a  large  nucleus  and  proc- 
esses. 

Section  III. — Chemistry 

Neuroglia, — One    point   in    the    chemistry    of    the    neuroglia 
should  preface  this  section — i.  e.,  the  processes  of  these  cells  be- 


48 


TREATISE    OX    XERVOUS    DISEASES 


come  charged  in  their  chemical  and  physical  characters  so  that 
they  take  on  different  stain  from  that  of  the  cell  body  itself 
(Weigert).  The  scavenger  cells  of  Lewis  are  the  neurogliar  cells 
produced  by  inflammatory  irritation  which  carry  off  irritating 
products;  and  this  must  he  some  form  of  chemical  combination  as 
yet  awaiting  the  physiological  chemist  to  solve. 

Nervous  Tissue. — According  to  Krause  and  Bischoff,  the  spe- 
cific gravity  of  nervous  tissue  is  1.036;  that  of  the  brain  1.038, 
of  the  spinal  cord  and  nerves  1.034.  The  reaction  is  alkaline 
owing  chiefly  to  the  production  of  lactic  acid. 

Water  makes  up  three-fourths  of  nervous  tissue.  There  is 
more  water  in  the  gray  than  in  the  white  matter,  and  least  water 
in  the  sympathetic  nerves.  Inorganic  salts  are  about  5  per  cent 
of  the  total  constituents  of  nerve-tissue.  According  to  Breed, 
phosphorus  is  the  largest  single  element,  and  it  is  combined  with 
calcium,  magnesium,  sodium,  potassium,  and  iron-forming  phos- 
phate salts.  Chloride  of  potassium  is  the  most  unportant  of  the 
other  constituents. 

Table  of  Chemical  Constituents  of  Nervous  System 
(Baumstark — quoted  by  Hammerstein  and  by  Dana) 


Gray  matter. 


Water  in  1,000  parts 

Solids   "       "       "     

T,    ,  (  cerebrin 

Protagon    j  j^^-^j^.^  ^^^^^-^^^ 

Insoluble  albumin  and  connective  tissue 

Cholesterin 

Nuclein 

Neurokeratin , 

Inorganic  salts 


769.97 
230.03 

10.08 

60.79 
23.81 

1.99 
10.43 

5.63 


Protagon  is  a  complex  substance  of  .atty  matter  containing 
nitrogen,  united  with  glycerin-phosphoric  acid  instead  of  glyc- 
erin. This  protagon  is  made  up  of  two  bodies,  cerehrin  and  leci- 
thin, the  latter  of  which  contains  an  ammonia  compound  called 
neurin.  Protagon  is  especially  abundant  in  the  white  matter. 
The  gray  matter  contains  nuclein,  important  in  cell  metabolism. 
Kuclein  (C29H49N9P3O22  Miescher)  consists  of  nucleic  acid,  a  sub- 
stance rich  in  phosphorus  and  a  various  amount  of  albumin.  The 
Qerve-cells  (gray  matter)  also  contain  various  amounts  of  albumi- 


ANATOMY,    PHYSIOLOGY,    A^B    CHEMISTRY       49 

nous  substances.  According  to  Halliburton,  nuclein  and  its  con- 
gener nucleo-aJbumin  are  designated  alluminoids.  They  both  con- 
tain albumin  and  are  found  chiefly  in  the  nucleus.  The  albu- 
minous substances  are  also  called  proteids  and  contain  little  or  no 
pliosphorus  and  make  up  most  of  the  cytoplasm  or  cell  body. 


CHAPTEE    II 

GENERAL  PATHOLOGY 

Ti-iE  nervous  system,  composed  as  it  is  of  nerve-cells  and 
fibres  forming  the  neurones,  the  connective  tissue,  the  neuroglia, 
blood-vessels,  and  lympliatics,  must  have  in  it^  pathology  disease 
of  one  or  many  of  these  structures.  Most  diseases  affect  the 
blood-vessels,  connective  tissue,  or  neuroglia  primarily,  and  paren- 
chyma secondarily,  although  in  many  affections  it  still  remains 
doubtful  which  is  first  diseased. 

Forms  of  disease  which  affect  the  nervous  system  are,  there- 
fore, as  follows: 

1.  Functional  and  nutritive  disorders,  including  those  of  meta- 
bolic and  glandular  defects  as  in  exophthalmic  goitre,  cretinism, 
or  myxoedema  and  acromegaly. 

2.  Malformations,  lack  of  proper  development  or  agenesis;  de- 
fective development  or  dysgenesis. 

3.  Anfemia,  ha?morrhage,  and  arterio-venous  disease. 

4.  Atrophy,  degeneration,  softening,  gliosis,  and  sclerosis. 

5.  Hyperemia,  oedema,  and  inflammations. 

6.  Tumours,  parasites   (echinococcus,  etc.). 

7.  Syphilis,  tuberculosis. 

Under  nutritive  and  functional  disorders  of  the  nervous  system 
come  defects  in  metabolism,  as  uric-acid  diathesis  causative  of  a 
certain  number  of  cases  of  neurasthenia;  also  under  this  .comes, 
as  Just  mentioned,  other  autochthonous  poisons  such  as  leuco- 
maines.  Then  come  the  extrinsic  poisons,  as  ptomaines  developed 
from  intestinal  intoxication,  etc. 

Sclerosis  is  a  process  of  connective-tissue  ^Drolif  eration  in  which 
the  normal  parenchymatous  tissue  is  supplanted  by  connective  tis- 
sue. This  is  the  result  of  degeneration  (next  to  be  considered). 
Neuroglia  overgrowth  also  usually  occurs  in  sclerosis. 

Degenerations  may  be  divided  as  follows,  into  acute  and 
chronic;  and  these  again  are  subdivided  into  primary  and  secondary 
50 


GEKEEAL   PATHOLOGY  51 

and  mixed.  Under  primary  come  the  progressive  muscular  atro- 
phies of  spinal  origin^  myelomalacia  and  tabes  dorsalis,  or  any  of 
the  system  diseases  of  the  cord.  Under  secondary  degenerations, 
we  may  give  as  examples  secondary  lateral  sclerosis  as  in  that  fol- 
lowing upon  hemiplegia  of  cerebral  origin  or  in  degeneration 
(diffuse)  of  the  cord  following  chronic  myelitis  or  syringomyelia. 
Acute  degeneration  usually  brings  about  a  softening  or  necrosis. 
If  repair  occurs  a  cicatrix  is  formed. 

Primary  degenerations  are,  of  course,  due  to  inherent  defect 
in  nutrition  or  to  some  poison  (as  that  of  syphilis  in  the  fourth 
stage)  acting  directly  on  the  fibre  or  cell.  Secondary  degenera- 
tion is  per  contra  due  to  separation  of  the  nerve-fibre  or  cell  from 
its  trophic  centre,  or  to  cutting  off  of  its  vascular  supply,  or  to 
injury  as  in  pressure  neuritis,  etc. 

The  most  usual  extrinsic  poisons  that  cause  degenerations  are 
arsenic,  lead,  phosphorus,  or  the  poisons  of  infectious  diseases 
as  of  la  grippe.  Endarteritis  and  arteriosclerosis  of  old  age 
also  cause  degenerations  by  obliterating  tlie  lumen  of  vessels, 
and  thus  preventing  proper  nutrition  of  the  part  beyond.  There 
is  a  legion  of  causes  which  with  all  our  scientific  advancement  are 
as  yet  unknown,  but  are  productive  of  premature  death  of  the  cell. 
Whether  certain  scleroses  are  forms  of  proliferative  inflammation 
is  as  yet  also  a  debated  question  by  pathologists,  although  the  tend- 
ency is  now  to  term  the  so-styled  chronic  inflammations  as  really 
degenerative  processes,  and  that,  as  indicated  above,  the  primary 
trouble  is  in  the  parenchyma. 

Gliosis. — Dejerine  is  the  leader  of  the  French  school  who  be- 
lieves that  some  of  the  chronic  degenerative  diseases  are  due  to 
proliferation  of  neuroglia.  This  overgrowth  of  neurogliar  tissue 
rather  than  connective  tissue  is  termed  gliosis. 

Inflammations. — Since  the  pathology  of  most  of  the  types  of 
disease  above  outlined  are  given  under  their  respective  heads,  we 
shall  dwell  upon  the  main  pathologic  changes  only  in  this  chapter. 

Inflammation  should  be  understood  as  to  its  nature,  as  the 
student  should  also  have  a  clear  comprehension  of  degeneration  of 
nerve-tissue.  Inflammation  has  primarily  to  do  with  blood-vessels, 
then  lymphatics,  and  finally  formation  of  connective  tissue.  It  is 
the  reaction  of  an  organism  to  an  irritant,  so  that  wherever  there 
is  inflammation  there  has  been  irritation.  Products  of  growths  of 
micro-organisms,  or  some  irritant  the  product  of  tissue  change,  are 


5^  TEEATISE   OK   KERVOUS   DISEASES 

usually  the  immediate  causes  of  the  irritation.  But  certain  chem- 
ical substances^  as  alcohol,  lead,  or  arsenic,  as  previously  men- 
tioned in  this  section,  may  produce  inflammations  directly;  al- 
though they  are  more  apt  to  be  causative  of  primary  or  degener- 
ative (destructive)  processes. 

When  the  irritant  is  removed,  inflammation  tends  to  subside — 
i.  e.,  it  is  then  regressive  not  a  progressive  process. 

Inflammations  are  further  divided  into — 

1,  Productive  forms  (Delafield). 

2.  Exudative  forms — these  forms  may  be  simple  inflammations, 
vs^ithout  necrosis  or  with  necrosis,  purulent  or  purulent  and  ne- 
crotic. 

Productive  or  proliferative  inflammation  is  a  process  in  which 
there  is  little  congestion  and  exudation,  but  new  connective  tissue 
sloivly  forms.  It  is  usually  chronic.  Examples  of  this  form  are 
syphilitic  or  tubercular  inflammations  (producing  specific  granu- 
lomata  or  tubercles).  Lead,  alcohol,  arsenic  may  also  produce  this 
form,  as  may  the  poisons  of  rheumatism,  gout,  diabetes,  states  of 
inanition  (^^sewiio-palsies  of  rickets,  etc.). 

Exudative  inflammation  is  associated  with  first  a  congestion, 
then  stasis,  exudation  of  white  blood  corpuscles  (amoeboid  move- 
ment), diapedesis  of  the  red  blood  cells,  transudation  of  blood 
serum,  the  final  formation  of  fibrin;  the  complete  result  being  an 
exudate  containing  white  blood  cells,  now  called  pus  cells,  and 
fibrin.  In  some  instances  there  is  no  destruction  of  tissue  in  this 
form  of  inflammation,  and  after  its  subsidence  the  tissues  affected 
return  to  the  normal  state.  In  other  cases  the  nerve  tissue  is 
partly  destroyed.  In  the  purulent  form  there  is  great  increase  of 
pus  cells  and  but  little  fibrin.  If  the  tissue  is  also  destroyed  it  is 
a  purulent  and  necrotic  form  of  inflammation.  In  some  forms  of 
exudative  inflammation  increase  of  connective  tissue  takes  place 
from  the  outset,  and  this  latter  continues  until  the  inflammation 
subsides.  Most  forms  of  this  exudative  type  are  acute  or  subacute. 
Inflammatory  oedema,  so  called,  is  of  this  type  of  inflammation. 

ISTerve-cells  proper  once  destroj^ed  never  re-develop.  This  is 
not  true  of  nerve-fibres,  and  while  these  frequently  develop  again, 
they  but  seldom  do  so  within  the  tracts  of  the  central  nervous  sys- 
tem. The  peripheral  nerves  when  regenerating  always  grow  from 
their  trophic  centre.  ISTerve-tissue  in  brain,  cord,  or  nerve  will  not 
reunite,  after  section,  by  direct  union.    With  but  very  few  excep- 


GENEEAL    PATHOLOGY  63 

tions  there  is  a  primary  degeneration  of  the  cut  ends,  which  is  then 
followed  by  regeneration.  JSTervons  tissue  is  further  dependent 
upon  its  blood  supply  and  its  trophic  connection  for  its  vitality. 
The  nerve-cell  is  absolutely  dependent  on  the  blood  supply,  while 
the  neuraxone  is  dependent  upon  the  trophic  influence  of  its  con- 
necting cell,  though  it  can  survive  for  a  time  the  simple  exclusion 
of  its  blood  supply.  If  the  neuraxone  is  injured  it  affects  the  cell, 
which  can  be  repaired,  however. 

Tumours  will  be  described  under  the  heading  of  Neoplasms. 


CHAPTER    III 
GEXERAL  SYMPTOMS  AXJJ   METHODS  OF  EXAMIXATIOX 

NOMENCLATURE    IN    NERVOUS    DISEASES 

Neurosis  applies  to  a  functional  condition  of  the  nervotis  S5's- 
tem,  wherein  the  higher  centres  (of  the  mindj  are  not  involved, 
snch  as  in  neitrasthenia. 

"Where  the  higher  faculties  of  mind  are  involved  the  name  psy- 
chosis is  given,  as  in  hysteria  or  insanity. 

Stupor  is  that  state  of  nnconscionsness  in  which  the  patient 
can  he  partially  or  completely  aroused;  and  in  "which  the  reflexes 
are  preserved. 

Coma  is  that  state  of  nnconscionsness  from  which  the  patient 
cannot  he  aroused  and  wherein  the  reflexes  are  ahsent. 

HypercEstJiesia  is  a  term  used  to  indicate  increased  sensibility. 

Hypcesthesia  applies  to  decrease  of  sensation. 

Parrpsfhesia  is  a  perversion  of  common  sensation,  such  as  ting- 
ling, nunibness.  or  formication,  which  latter  is  a  sensation  as 
though  ants  were  crawling  over  the  body. 

Spasm  or  convulsion  is  a  sjTnptom  in  which  there  is  violent 
contraction  of  the  muscles,  and  may  he  localized  or  general.  Fre- 
quentlv  spasm  is  used  in  the  sense  of  a  localized  convttlsion  alone, 
although  this  is  not  technically  correct,  and  local  spasm  is  prop- 
erly called  "tic,"^  such  as  "tic""  of  the  face — a  spasm  of  the 
seventh  nerve.  Convulsions  are  further  divided  into  clo?iic  and 
tonic.  In  the  former  the  movements  are  in  rapid  succession,  and 
in  the  latter  the  contraction  is  maintained  for  a  long  period  of 
time.  Hysterical  convulsions  are  partienlarly  apt  to  be  of  a  tonic 
nature.     (See  illustration,  p.  56.) 

There  are  certain  definite  affections  of  different  tracts  of  the 
central  nervous  system  which  are  given  special  prominence  in  the 

>  Tic  may  also  apply  to  a  painful  paroxysm  in  neurological  nomenclature; 
bat  then  the  Tpre&x painful  is  used  in  explanation,  or  an  afl&x  as  in  '[tic  doulou- 
reux.'^ 

54 


GUIDE   TO   XOTE-TAKIXG 

IXFIRMARY    FOR   XERVOUS   DISEASE,    PHILADELPHIA 

Xo.  of  Case.     Xame  of  Book.     Date.     Service  of  Doctor. 
Xame.     Eesidence.     Age.     Sex.     Eace. 
General  Statement  to  Aid  in  Classifying  Case. 
Family  History: 

Hereditary  Tendencies — Healtli  of  Parents — Syphilis— Gout — Diabetes, 

etc. 

Personal  History : 

Married  or  Single — Children — Relation  of  Work  to  Present  Trouble — ■ 
Illnesses  —  Injuries  —  Syphilis  —  Xervous  Diseases — Habits — Tempera- 
ment— -Life,  Active  or  Sedentary — Occupation — Exposure  to  Poisons — 
Malaria  —  Lead  —  Tobacco — Alcohol — Xarcotics— Opium,  etc. — Usual 
Weight — Height. 

Date  of  Onset  of  Present  Trouble : 

Supposed  Cause — ]\[ode  of  Onset  and  Outline  of  Course. 

General  Aspect : 

Weight  now— Colour — Skin — Hair — Eyes — Scars  on  Head,  etc. 

State  of  Organs: 

Present — Comparing  Pa"fet. 

1.  Digestion: 

Tongue — Bowels — Appetite — Rectum — Teeth — Liver — Spleen — Taste. 

2.  Eespiration : 

Lungs — Throat — Xose — Smell. 

3.  Circulation: 

Heart — Pulse — Arterial  Tension — Blood — CEdema. 

4.  Uro-Genitory : 

Catamenia  —  Leucorrhoea  —  Displacements  —  Phimosis  Scars — Sexual 
Functions  —  Power,  etc.  — Urinalysis — Colour  —  Sp.  Gr.  — Albumen — 
Sugar — Uric  Acid — Oxalates — Urates. 

5.  iSTervous  System : 

(a)  Motility — Voluntary  Movements — Strength — Grasp — Co-ordination 
— Spasms — Reflex  Capacity — Knee-Jerk — Arm-.Jerk — -Jaw-Jerk — Skin — 
Cremaster,  etc. — Muscle- Jerks— Clonus — Station — Sway — Bladder  Con- 
trol. 

(6)  Sensibility — Subjective  Sensations — Hyperfesthesia — Anaesthesia,  etc. 
— To  contact  (^l^sthesiometer),  to  pain,  to  temperature — Intellectual 
Functions^Hallucinations — Delusions — State  of  Will — Predominant 
Ideas — Specify  Insane  Acts — Sleep — Vertigo — Tenderness  over  Xerves — 
Headaches — Electrical  Examination — Trophic  Alterations — Vaso-motor 
Activities. 

6.  Sight: 

Vision  (Type  —  Fingers — Colours) — Field  —  Fundus — Ocular  Muscles 
— Pupils. 

7.  Hearing: 

Deafness — Wax — Tinnitus. 

55 


56  TEEATISE    OX    NERVOUS    DISEASES 

study  of  diseases  of  the  nervous  system,  and  lead  to  assist  in  the 
diagnosis  through  knowing  the  results  of  anatomical  or  physiolog- 
ical perversions  in  them.  In  the  sensory  tracts  we  have  mani- 
fested pain,  dull  or  shooting  in  character;  parcesthesia,  or  numb- 
ness of  a  part;  causaJgia,  or  burning  pain,  frequently  occurring 
in  peripheral  neuritis — all  due  to  irritative  lesions  of  these  tracts. 
A  diminution  of  the  function  of  the  sensory  tracts  will  produce 

hypsesthesia,  angesthesia. 
Different  distributions  of 
anesthesia  are  of  nerve- 
trunJc,  the  circumscribed, 
the  s'igmental  or  glove-like 
— ^where  the  anaesthesia  ex- 
tends up  an  entire  extrem- 
ity, such  as  from  the  finger- 
tips to  the  elbow,  as  in 
cases  of  hysteria.  Hemian- 
esthesia is  a  condition 
where  half  of  the  body  is  in- 
\  volved — this    being    of   two 

%  different       kinds  —  organic 

and  functional,  a  point  of 
difference  being  that  func- 
tional   or    hysterical    anses- 
^^^^  thesia,  so  called,  has  a  dis- 

^HHB^I^  tinct   dividing   line   in   the 

^^^^^1*^^      median  line  of  the  body — 

■  ^mMB       ^^'hereas   organic  hemianses- 

■  .^A.E»      thesia   will    extend   slightly 
Fig.  10.— Position  of  Hand  in  Local  Tonic      j^evond  the  median  line,  due 

Hysterical  Spasm  .    "    ,^         t  _l  i  •  f 

to    the    distal    crossing    ot 

nerve-fibres  beyond  the  median  line ;  or,  better,  this  latter  is  anges- 

thesia  from  the  centre  to  the  ultimate  end  of  the  nerve-twigs.    The 

destructive  lesion  of  the  spinal  cord  involving  one-half  of  it  will 

produce  symptoms  of  complete  hemiangesthesia  and  slight  motor 

loss  below  the  site  of  lesion  on  the  opposite  side,  with  complete 

motor   loss    on   the    side    of  lesion.     Tsually   it   is    only   pain 

and  temperature  sense  that  are  lost,  since  the  lesion  is,  as  a  rule, 

limited.      This    is    called    Brown-Sequard    paralysis,   named    for 

him  who  first  described  it,  and  is  due  to  the  fact  that  the  sen- 


SYMPTOMS  AND  METHODS  OF  EXAMINATION  57 


sory  fibres  upon  entering  the  cord  cross  to  the  opposite  side,  then 
pass  up. 

In  pontine  lesions  we  may  have  a  hemiansesthesia  of  same  side 
of  the  face  with  motor  and  sensory  palsy  on  the  opposite  side  of 
the'  body  to  the  lesion. 

Algesia  refers  to  the  pain  produced  in  a  part  either  by  external 
or  subjective  stimulation  of  sensory  nerve-fibres  or  neurones. 

Muscle  sense  is  that  phenomenon  by  which  we  distinguish  space, 
shape,  size ;  also  the  location  of  parts  of  the  body. 

Asteriognosis  refers  to  the  inability  to  appreciate  dimensions, 
density,  and  shapes  of  objects. 


Fig.  11. — Krauss's  Plessimeter. 

By  unscrewing  the  caps  C  and  D  it  may  be  used  as  an  sesthesiometer, 
or  as  a  brush  for  testing  tactile  sensibility. 


Temperature  sense  is  the  faculty  of  appreciating  temperatures 
of  bodies^  such  as  heat  and  cold. 

Reflexes  are  phenomena  produced  by  irritation  or  by  stimu- 
lants of  some  sort  either  from  within  or  from  without.  Ordinarily, 
the  reflex  consists  of  an  afferent  impulse,  which  is  carried  over 
the  sensory  tract  to  the  nerve-centre  in  the  cord  or  brain.  The 
impulse  is  then  transmitted  to  the  centre,  which  consists  of  a 
collection  of  nerve-cells  within  the  cord  or  brain;  and  finally  the 
efferent  impulse  completing  the  reflex  is  carried  over  the  motor 
tract  or  fibres  from  the  nerve-centre,  producing  motion,  secretion, 
and  various  physiological  phenomena  of  the  body,  depending  upon 
the  nature  of  the  reflex  action. 

Eeflexes  are  divided  into  superficial  and  deep  and  visceral. 
Superficial  are  those  occurring  upon  the  surface  of  the  body,  such 
as  skin  and  mucous  membranes.  We  have  among  them  the  pupil- 
lary sTcin  reflex,  which  consists  of  a  dilatation  of  a  pupil,  produced 
by  the  irritation  of  the  skin  of  the  neck,  as  in  pinching  the  same, 
the  impulse  being  carried  up  by  the  cervical  sensory  nerves,  and 
down  as  a  motor  impulse  through  the  motor  sympathetic  nerve- 
fibres  to  the  dilator  muscles  of  the  pupil.    The  pectoral  reflex  con- 


TEEATISE    ON    NERVOUS    DISEASES 


sists  in  contraction  of  the  pectoral  muscles  through  the  skin  over 
them.  The  epigastric  reflex  consists  in  a  contraction  in  the  epi- 
gastric region  through  the  fibres  of  the  recti  muscles.  The  abdom- 
inal reflex  consists  of  contraction  of  the  abdominal  muscles  when 
the  abdomen  is  irritated.  The  supra-orhital  reflex  of  McCarthy 
consists  in  elevation  of  the  lower  lid  when  the  supra-orbital  region 
is  gentty  tapped.  There  are  a  number  of  others  not  of  practical 
importance  to  the  student. 

r  '  ^™ 


Fig.  12.— Showing  the  Jendrassik  Method  of  Obtaining  the  Knee-Jerk. 


The  cremasteric  reflex  consists  in  retraction  of  the  testicle 
when  the  skin  of  thigh  is  irritated. 

The  plantar  reflex  consists  of  flexion  of  the  toes  when  sole  of 
the  foot  is  irritated. 

The  palmar  reflex  consists  in  jerking  of  hand  and  closing  of 
the  fingers  upon  irritating  the  skin. 

The  infra-orbital  reflex  consists  of  the  elevation  of  the  lower 
eyelid  when  the  supra-orbital  region  is  irritated  by  a  blow. 


SYMPTOMS  AND  METHODS  OF  EXAMINATION  59 

Deep  reflexes  or  muscle  reflexes  are  produced  by  tapping  a  muscle 
or  tendon  and  causing  contraction  of  the  muscle.  The  knee-jerk 
is  produced  by  tapping  the  ligamentum  patella,  the  leg  being 
loosely  pendant  at  right  angles  to  the  thigh.  There  is  extension 
of  the  leg. 

The  tendo-Achillcs  reflex  is  produced  by  tapping  the  tendo- 
Achilles,  when  extension  of  the  foot  will  occur,  due  to  the  con- 
traction of  the  gastrocnemius  group  of  muscles. 

The  contra-lateral  or  adductor  femoris  reflex  is  one  pro- 
duced by  tapping  the  ligamentum  patella  on  one  side,  the  patient 
sitting  on  the  edge  of  a  chair  with  both  limbs  loosely  resting  on 
the  feet.  If  this  reflex  is  present  adduction  of  the  opposite  thigh 
will  occur.  This  is  an  inconstant  reflex,  and  although  it  cannot 
be  said  to  be  pathological  in  significance,  it  is  much  increased  in 
cases  of  spastic  disease,  as  a  rule,  especially  when  involving  the 
lateral  columns  of  the  cord. 

Anlde  clonus  is  a  deep  reflex,  always  pathological,  and  is 
produced  by  sudden  flexion  of  the  ankle,  the  physician  support- 


Tatlor  Knee-Jerk  Hammer. 


ing  the  calf  with  one  hand  and  firmly  pressing  on  the  sole  or 
ball  of  the  foot  quickly.  If  present  there  will  be  a  to-and-fro 
clonic  involvement  of  the  foot  due  to  contraction  of  the  soleus  ^ 
and  gastro-intestinal  muscle.     This  is  called  true  ankle  clonus. 

A  psuedo-anhle  clonus  is  that  inconstant  clonic  contraction  of 
the  same  muscle  group,  occurring  in  neurasthenia  or  hysteria.  It 
is  also  called  abortive  ankle  clonus,  since  it  is  soon  exhausted.  It 
does  not  signify  organic  disease  of  the  cord,  as  the  true  form 
always  doee. 

The  elhoiv-jerh  consists  in  the  extension  of  the  elbow,  produced 
by  tapping  the  tendon  of  the  triceps  muscle  when  the  arm  is  held 
pendant  over  the  table  or  other  object. 


»  Weir-Mitchell  believes  it  is  entirely  due  to  action  of  the  soleus. 


60 


TREATISE    OX   is^EEYOUS    DISEASES 


The  hiceps-jerh  corftists  in  flexion  of  the  elbow,  when  the  biceps 
tendon  or  muscle  is  suddenly  tapped. 

The  extensor  reflex  of  the  wrist  consists  of  the  extension  at  the 
wrist  when  the  extensor  group  of  muscles  are  tapped. 

The  icrist  reflex  proper  consists  in  flexion  when  the  flexor  mus- 
cles are  tapped. 


Fig.  14.— Showing  Method  of  Obtaining  the  Triceps  and  Supinator  Jerk. 

The  jaw-jerk  consists  in  sudden  closing  of  the  mouth  when 
tapping  over  the  mental  process  of  the  inferior  maxilla. 

Paradoxical  contraction  consists  of  a  tonic  contraction  of  the 
anterior  tibial  muscles,  produced  by  a  sudden  flexion  of  the  foot 
or  the  leg.  This  sudden  shortening  of  the-  muscles  indicated 
causes  the  tonic  spasm  which  is  always  pathological. 

Superficial  and  deep  reflexes  are  said  to  be  increased  when  there 


SYMPTOMS    AND    METHODS    OF    EXAMINATION  61 

is  a  decided  increase  of  tiie  movement  over  the  normal;  lessened 
when  there  is  a  lessening  of  the  normal  amount  of  movement  upon 
its  development.  Of  course  reflexes  are  absent  where  no  response 
occurs.  The  two  extremes  of  reflex  action  are  spastic  where  the 
reflexes  are  greatly  increased,  and  absent  when  there  is  no  reflex 
at  all  produced  on  external  stimulation.  Several  other  terms  are 
used  in  describing  reflexes,  such  as  moderately  increased  and 
greatly  increased,  and  related  to  the  spastic  as  described.  Also 
the  other  extreme — slightly  diminished  and  greatly  diminished, 
exists  before  abolition  of  the  reflexes  occurs. 

Visceral  reflexes  is  the  third  group,  and  consists  of  the  ac- 
tion of  the  various  viscera,  etc.,  induced  by  irritative  phenom- 
ena; as  the  peristaltic  movements  of  the  stomach,  after  taking 
of  food. 

The  Eye. — The  light  reflex  is  produced  by  throwing  a  bright 
light  into  the  eye,  causing  contraction  of  the  pupil.  Accommoda- 
tion reflex  is  brought  out  by  causing  the  subject  to  look  at  a  near 
object  when  the  pupil  also  suddenly  contracts.  When  the  light 
reflex  is  lost  and  accommodation  is  still  present  the  Argyll-Robert- 
son pupil  is  said  to  exist. 

Eeflexes  of  the  bladder,  rectum,  and  sexual  apparatus  are  also 
important;  the  two  former  being  under  control  of  the  higher 
centres.  'If  the  tone  of  the  compressor  urethra  is  intact,  the  reflex 
being  lost,  we  have  incontinence  of  overflow  as  a  sign. 

Damage  to  the  genital  reflex  arc  causes  loss  of  erection  and 
sexual  desire.     Loss  of  inhibition  may  cause  priapism. 

TROPHIC,  VASO-MOTOR  AND  SECRETORY 
PHENOMENA 

By  trophic  disturbances  we  refer  to  certain  conditions,  as  the 
wasting  of  muscles,  false  hypertrophy  of  muscles,  bedsores,  joint 
disease,  trophic  changes  in  same,  such  as  the  arthropathies,  brittle- 
ness  of  the  nails,  hypertrophy  of  bone,  such  as  in  Paget's  disease, 
where  the  cranial  bones  are  enlarged. 

Vaso-motor  disturbances  refer  to  the  conditions  dependent 
upon  disease  of  the  nervous  system,  as  flushing,  cedema,  angeio- 
neurotic  oedema,  coldness  and  clamminess  of  the  extremities. 

Secretory  phenomena  and  disturbances  thereof,  consists  of, 
among  others,  retention,  or  too  much  elimination  of  certain  secre- 
tions; in  the  former  in  the  case  of  the  thyreoid  gland,  we  have 


62 


TREATISE    OK    KERYOUS    DISEASES 


developed  a  disease  to  be  studied  in  another  chapter — cretinism 
and  myxcedema.  Excess  of  thyreoid  secretion  probably  occurs  in 
exophthalmic  goitre. 


EXAMINATION   OF  THE 
PATIENT 

Examination  of  the  patient  for 
nervous  disease  includes  a  study  the 
most  thorough  in  general  medicine,  in 
order  to^  exclude  other  maladies;  and 
specifically,  of  course,,  for  the  deter- 
mination of  the  status  of  the  nervous 
system.  It  will  be  in  keeping  with  the 
book  to  pass  by  intricate  medical  meth- 
ods, therefore,  insisting  upon  their  im- 
portance, however,  and  to  hasten  on  to 
the  examination  of  the  nervous  system 
itself. 

Gait  and  Station. — Station  is  the 
attitude,  the  manner  of  holding  the 
body  in  the  upright  posture,  the  feet 
being  in  the  position  of  "atten- 
tion." The  station  is  said  to  be  normal  when  the  patient  but 
slightly  deviates  from  the  erect  posture  while  standing,  the 
sway  tending  towards  no  particular  direction.  The  station  is 
said    to    be    ah  normal   when    the    patient    does    sway    markedly. 

In   designating   this    symp- 


FiG.    15. — Weir     Mitchell's 

APPARA.TUS   FOR  CLINICAL  OB- 
SERVATIONS OF  Station. 


torn,  right,  left,  forward  or 
backward  are  used  to  indi- 
cate   the    direction    of    the 
abnormal    deviating    move- 
ment.      An    unsteady    sta- 
tion    is    called     Romberg's 
sign,  particularly  found  in 
tabes. 
The  sway  should  also  be  tested  with  the  eyes  open  and  with  the 
eyes  closed,  since  it  will  always  be  found  more  perverted  when  the 
eyes  are  shut,  especially  in  diseases  where  muscular  sense  is  much 
dfsturbed,  as  in  tabes,  referred  to  above. 


Fig.  16. — Foot  Dynamometer. 


SYMPTOMS    AND    METHODS    OF    EXAMINATtON  63 

Gait  is  the  manner  of  progression  of  the  individual.  It  is 
to  be  noted  that  there  is  a  difference  between  the  normal  gaits  of 
the  two  sexes.  The  female,  due  to  the  breadth  of  the  hips,  has  a 
more  or  less  waddling  progression,  whereas  the  male  movement  is 
more  directly  forward  in  walking. 

Patients  should  not  deviate  from  the  direct  line  of  progression 
in  any  one  direction  more  than  another,  although  a  natural  sway 
does  occur,  and  there  are  particular  family  types  of  normal  pro- 
gression. 

Grasp  is  determined  by  the  dynamometer.  It  is  of  use  to 
compare  palsy  of  the  hand  and  forearm  muscles. 

PATHOLOGIC   GAITS 

1.  Hemiplegic,  or  that  type  in  whiclifthe  individual  carries  one 
side  of  the  body  forward  with  the  muscular  action  of  the  unaf- 
fected side,  plus  gravity.     The  patient   brings  the   affected  leg 


Fig.  17. — Hand  Dynamometer. 


forward  in  flail-like  fashion,  using  the  opposite  foot  as  a  pivot, 
the  toe  of  the  affected  side  dropping  to  the  ground  before  the 
step  is  completed,  so  that  a  tracing  of  this  gait  will  present  a 
short  stride  of  the  affected  side,  followed  by  the  longer  stride  of 
the  healthy  limb. 

2.  Spastic  is  one  characterized  by  the  forcing  of  the  toes  down- 
ward in  flexion  during  progression.  In  its  incipiency  the  wearing 
out  of  the  toe  of  the  shoe  may  be  the  most  prominent  sign.  Later 
the  ball  of  the  foot  is  "  dug  "  into  the  floor,  the  patient  stumbling 
over  the  slightest  impediment.     The  knee-jerk  is  found  to  be  in- 


64  TREATISE    Oif   NEEVOUS    DISEASES 

creased,  though  it  may  be  difficult  to  elicit  on  account  of  flexor 
contractions. 

3.  Ataxic  is  one  where  the  patient  throws  the  limb  outward, 
forward,  and  downward,  the  heel  dropping  first,  and  all  the  move- 
ments being  inco-ordinate.  This  gait  is  decidedly  worse  when  the 
patient  is  in  the  dark  or  when  closing  his  eyes.  The  knee-jerk  is 
usually  absent.    It  is  increased  in  ataxie-paraplegia. 

4.  Titubation  is  characterized  by  a  rather  sudden  deviation 
to  right  or  left  during  progression.  As  a  rule,  the  patient 
"  catches  "  himself  before  more  than  one  or  two  steps  away  from 
the  normal  are  made.  This  gait  is  rather  characteristic  of  the 
inco-ordination  produced  by  cerebellar  disease  where  centres  for 
balance  lie. 

5.  Steppage  gait  is  that  in  which  the  patient  lifts  the  toes 
high  from  the  surface,  such  as  normally  is  done  in  ascending 
stairs.  The  cause  for  this  exaggeration  lies  in  the  fact  that  there 
is  palsy  of  the  anterior  muscles  of  the  leg.  This  gait  occurs  in 
neuritis  and  the  muscular  dystrophies.  It  is  almost  pathogno- 
monic of  these  conditions. 

6.  Festinating  gait  (or  running  gait).  Here  the  patient  tends 
to  go  forward  rapidly,  as  in  paralysis  agitans,  in  which  disease 
a  sensation  of  falling  forward  (propulsion)  or  backward  (retro- 
pulsion)  may  also  occur. 

PHYSIOGNOMY 

Physiognomy  of  the  patient  has  much  to  do  with  the  deter- 
mination of  certain  features  of  the  nervous  malady.  Besides  the 
final  delineations  of  feature,  showing  depressive  mental  states  or 
the  opposite,  a  temperament  is  shown  by  the  examination  of  the 
facies,  of  which  the  following  are  of  some  worth  in  stud3dng  the 
case — namely: 

Lymphatic  temperament,  in  which  the  face,  along  with  other 
structures,  presents  a  pale  and  waxy  sallow  aspect,  and  in  which 
the  subcutaneous  tissues  are  flabby  and  the  skin  is  unduly  wrinkled. 
Such  persons  are  apt  to  be  large  of  skeleton,  out  of  proportion  to 
the  musculature,  and  their  circulation  is  sluggish. 

Sanguineous  temperament  is  characterized  by  the  face  present- 
ing a  florid  complexion.  Prominence  and  tension  of  the  sub- 
cutaneous   tissues,    with    perhaps    excessive    development    of    fat 


SYMPTOMS   AIsTD    METHODS    OF   EXAMINATION  65 

cells,  is  seen;  the  neck  usually  appearing  short  and  the  chest 
broad,  out  of  proportion  to  the  general  physique.  It  should  be 
stated  that  this  type  is  predisposed  to  apoplexy  among  nervous 
diseases. 

Bilious  temperament  is,  typically,  found  in  those  with  dark 
hair  .and  complexion.  The  salient  features  are  tendency  to  jaun- 
dice, to  a  melancholy  physiognomy,  the  tongue  being  usually 
coated  and  bowels  constipated.  Such  types  are  likely  subject  to 
nervous  depressive  diseases,  such  as  hypochondriasis  and  melan- 
cholia, or  to  the  neurasthenias  dependent  upon  gastro-intestinal 
auto-intoxication  in  some  measure. 

Nervous  Temperament. — Here  the  individual  expression  is  one 
of  vivacity,  eyes  are  alert,  movements  quick;  with  a  miisculature 
that  is  not  large,  but  the  muscles  are  distinctly  outlined,  as  in  the 
thoroughbred,  the  bellies  being  prominent.  These  people  are  most 
likely  to  come  under  the  list  of  nervous  patients,  because  they  do 
the  world's  work. 

Neuro-Bilious  Temperament. — This  is  a  type  we  can  well  des- 
ignate in  America,  since  our  methods  of  life  conduce  to  modifica- 
tion of  the  other  temperaments  towards  the  nervous ;  and  since  the 
bilious  temperament,  as  indicated,  is  not  itself  an  important  factor 
in  nervous  disease,  but  when  added  to  by  the  nervous  element 
there  is  reason  to  make  the  above  designation.  This  type  is  the 
most  difficult  to  manage  in  any  case  of  nervous  or  mental  disease. 

DECUBITUS 

In  neurology  the  position  of  the  patient,  as  he  lies  in  bed,  is 
important  to  note  in  making  an  examination. 

In  decubitus  of  meningitis,  as  a  rule,  the  patient  lies  supine,  or 
on  his  side,  with  retraction  of  the  head  and  hyperextension  of  the 
back,  plus  general  muscular  rigidity. 

In  hemiplegia  the  patient  usually  lies  upon  the  back,  the  one 
side  of  the  body  being  assisted  by  the  normal  extremities. 

In  tetanus  and  hydrophobia  the  decubitus  is  not  consistent, 
but  is  somewhat  like  that  of  meningitis,  the  patient  more  frequent- 
ly remaining  on  the  side,  however.  Tonic  and  clonic  convulsions 
occur  spontaneously  or  with  the  slightest  reflex  excitement.  In 
both  of  these  diseases  there  is  frothing  at  the  mouth. 

Decubitus  of  an  epileptic  attack  consists  of  the  patient  lying  on 
5 


66 


TEEATISE    OK    NERVOUS    DISEASES  . 


the  back  usually  in  the  typical  convulsion,  with  conjugate  devia- 
tion of  the  eyes  and  dilated  pupils.  Following  the  attack  the 
patient  remains  limp,  supine.  He  may,  of  course,  fall  upon  his 
face  in  exceptional  instances. 

Decubitus  of  neuritis  is  not  constant,  depending  upon  the 
degree  and  extent  of  nervous  inflammation  and  palsy.  The  pa- 
tient always  tends  to  protect  the  extremity  or  part  affected,  and 
this  will  extend  to  the  guarding  of  the  extremity  from  any  injury 
or  contact,  as  of  the  bed-clothing,  when  there  is  active  neuritis. 


EXAMINATION    FOR    SENSATION 

This  is  done  by  means  of  the  sesthesiometer,  to  determine  the 
presence,  absence  (anaesthesia),  or  diminution  (hypassthesia),  or 
exaggeration  (Ii3^per8esthesia)  of  common  sensations.  Dysesthesia 
is  an  abnormal  sensation,  such  as  a  feeling  of  discomfort  pro- 
duced by  ordinary  tactile  or  painful  impres- 
sion. Parsesthesia  is  a  subjective  sensation, 
such  as  a  feeling  of  pins  and  needles  prick- 
ing the  affected  part,  and  occurs  frequently 
in  early  neuritis,  as  in  pressure  palsy. 

Causalgia  is  a  "burning"  sensation 
found  in  some  cases  of  neuritis  of  chronic 
type,  as  in  erythromelalgia. 

Formication  is  the  sensation  as  of  ants 
crawling  over  the  surface  of  the  skin;  often 
a  delusion  of  mental  disease. 

For  the  finest  determination  of  sense  of 
touch,  a  piece  of  cotton  twirled  at  the  end 
will  be  found  efficacious;  or  better  the  fes- 
thesiometer.  In  testing,  it  should  always  be 
done  symmetrically,  since  one  person  may 
differ  from  another,  according  to  the  tem- 
perament, so  that  a  standard  cannot  be  set 
for  all  persons  from  one  case.  It  should  be 
remembered,  too,  that  special  parts  of  the  body  are  more  sensitive 
than  others,  such  as  the  face  and  the  lips,  tongue,  and  palms  of  the 
hands  and  feet. 

To  test  the  thermic  sense,  heat  and  cold  are  applied  through 
water  in  test-tubes.     The  absence  of  thermic  sense  (thermo-anses- 


FiG.  18.— Carroll's 

^STHESIOMETER. 


SYMPTOMS  AND  METHODS  OF  EXAMINATION  67 

thesia)  is  to  be  expected  in  cases  of  syringomyelia,  where  the 
touch  sense  may  he  retained  in  tlie  absence  of  thermic  sensation — 
the  so-called  disassociaiion  of  sensation. 

Algesia  or  pain  sense  is  tested  by  means  of  a  sharp  instrument, 
as  the  Eesthesiometer.  This,  also,  may  be  absent  (analgesia)  with 
preservation  of  the  other  forms  of  sensation  in  some  eases  of  hys- 
teria, etc. 

EXAMINATION   FOR    MOTION 

The  motor  phenomena  are  examined  for,  first,  as  to  palsies. 
These  "can  be  tested  by  means  of  the  hand  or  foot  dynamometer, 
which  is  an  instrument  by  which  record  is  made  on  a  dial  of 
the  amount  of  force  used  to  compress  the  oval  spring.  In 
testing  the  strength  of  the  lower  extremity,  the  instrument  is 
suspended  from  the  shoulder,  and  by  means  of  a  strap,  attached 
also  to  the  dynamometer,  the  amount  of  pressure  can  be  regis- 
tered. This  should  be  used  bilaterally,  since  the  record  is  only 
for  comparison.  The  palsy  in  other  parts  is  noted  by  the  strength 
shown  in  movement  of  the  part  of  the  muscles,  as  in  effort  to 
lift  some  object,  etc.  Individual  muscle  palsies  are  noted  by  obser- 
vation, the  anatomical  position  of  the  part  involved,  and  in  rela- 
tion to  the  motor  nerve  supply,  thus  giving  way  to  opposing 
normal  muscles. 

The  opposite  of  paralyses,  convulsions,  are  determined  by 
means  of  the  sense  of  sight. 

A  contraction  is  a  shortening  of  the  muscle  of  a  part,  which 
cannot  be  forcibly  extended  even  under  etherization  of  the  patient. 

A  contracture  is  the  shortening  of  a  muscle,  which  can  be  re- 
lieved by  firm  extension,  the  muscle  therefore  not  being  actually 
organically  diseased.  It  may  be  necessary  to  etherize  the  patient 
to  accurately  test  this. 

Paralysis  may  be  partial  or  complete,  the  former  scientifically 
being  designated  paresis. 

The  forms  of  paralysis  are: 

Hemiplegia,  involving  one-half  of  the  body. 

Monoplegia,  where  the  palsy  is  confined  to  one  limb  of  the 
body. 

Paraplegia,  where  both  the  lower  extremities  are  affected. 

Diaplegia,  where  the  palsy  involves  corresponding  extremities, 
as  the  two  legs,  two  arms.  Or  all  four  limbs. 


68 


TREATISE    ON    NEEVOUS    DISEASES 


Loss  of  the  special  sensibility  of  the  muscles,  articular  sur- 
faces, and  tendons  produces  ataxic  movements. 

Ataxic  movements  are  inco-ordinate  movements,  as  in  loco- 
motor ataxia;  or  in  cerebellar  disease  or  in  neuritis.  Apprecia- 
tion of  weight  and  position  of  limbs  are  lost  in  ataxia. 

Static  ataxia  consists  in  loss  of  equilibrium  when  the  patient 
or  part  is  at  rest. 

Cerebellar  ataxia  is  produced  by  cerebellar  disease. 

Motion  of  an  unparalyzed  limb  or  a  limb  that  is  partially 
paralyzed  will  occasionally  produce  movements  in  the  correspond- 
ing paralyzed  extremity.  This  is  designated  as  associated  move- 
ment. A  forced  movement  is  one  produced  in  spite  of  the  patient's 
will,  as  when  the  patient  is  suddenly  whirled  about  in  various 
directions. 

Some  other  abnormal  movements  are  tremors,  spasms,  and 
choreiform  convulsions. 

Tremors  are  fine,  coarse,  intentional,  and  continual. 

The  following  table  gives  the  various  causes  of  tremor  and 
their  character : 


Cause. 


Toxic. 


Neuroses 


f  Arsenic. 
Lead. 
Alcohol. 
Tobacco. 
Tea. 
Coffee. 
Hysteria. 
Neurasthenia. 
Exophthalmic 
Goitre. 
Senility  , 

Heredity 

Any  disease  of  brain, 
spinal  cord,  or  periphe- 
ral nerves,  excepting 
multiple  sclerosis  and 
paralysis  agitans. 
Paralysis  agitans 


Type  of  tremor. 


Intention  in  early  stages : 
later  may  become  con- 
stant ;  may  then  be  in- 
creased by  exertion. 


Ibid. 


Multiple  sclerosis. 


Ibid. 
Ibid, 
Ibid. 


Often  ceases  for  a  few 
seconds  after  muscular 
exertion. 

Intention  only. 


Rapidity. 


Rapid. 


That  of  hysteria  some- 
times is  slow;  others 
always  rapid. 

Rapid. 
Rapid. 

May  be  slow  or  rapid,  or 
both  combined.  - 


Slow. 


Slow. 


Spasms  may  be  tonic  or  clonic,  the  latter  consisting  in  rapid 
movements;  but  when  the  contraction  persists  it  is  designated 
tonic;  when  permanently  persisting,  it  produces  what  is  called 
muscular  rigidity,  as  in  the  extremities,  neck,  or  trunk. 


SYMPTOMS  AND  METHODS'  OF  EXAMIXATIOX  69 

Choreic  movements  are  sudden,  or  jerking,  irregular  inco-ordi- 
nate  movements. 

Convulsive  tic  is  a  form  of  choreic  movement  confined  to  cer- 
tain groups  of  muscles  and  limited  to  muscles  physiologically 
grouped  for  certain  functions,  as  the  respiration,  or  expression,  or 
locomotor. 

Athetosis  is  the  vermicular  movement  described  first  by  Ham- 
mond, observed  in  cerebral  disease,  as  in  porencephaly. 

Conjugate  deviation  is  a  phenomenon  that  is  frequently  pres- 
ent in  diseases  of  one  side  of  the  brain.  In  this  the  eyes  are 
directed  towards  one  side  (of  lesion),  with  or  without  the  corre- 
sponding rotation  of  the  head. 

If  the  lesion  is  a  simj^le  irritative  one  the  deviation  is  away 
from  the  side  of  the  lesion.  The  first  is  paralytic,  the  latter  spas- 
modic. 

PRESSURE    SENSE 

Pressure  sense  is  determined  by  means  of  weights,  alternating 
one  with  the  other,  until  the  power  of  discrimination  is  nicely  met 
with  the  least  amount  of  weight.  Differences  of  temperature 
should  be  excluded,  also  the  prevention  of  the  displacement  of 
the  weights  in  this  test,  and  the  area  or  part  tested  should  be  held 
in  relaxed  position.  For  making  the  finer  tests  bits  of  cork  are 
used. 

MUSCULAR    SENSIBILITY 

This  test  depends  somewhat  upon  idiosyncrasy  of  the  individ- 
ual. To  exclude  surface  differences  in  testing  by  balancing 
weights,  they  can  be  suspended  in  a  towel  or  by  cords.  By  re- 
peated experiments,  it  is  thus  possible  to  determine  as  between 
the  cutaneous  sensibility  (which  will  interfere  with  the  test  to  the 
extent  of  two  or  three  ounces  pressure)  and  the  muscular  sense. 

The  pressure  sense  is  a  composite  physiological  phenomenon, 
consisting  of  the  sense  of  coarse  movements  of  the  limb,  the  pos- 
ture sense  and  the  pressure  sense. 

SENSE    OF    THE    APPLICATION    OF    WEIGHT 

This  is  determined  by  the  piesmeter  of  Beard  and  Eockwell, 
which  instrument  is  made  up  of  a  cylinder,  f  of  an  inch  in  diam- 
eter and  3  inches  long,  in  which  is  a  piston  kept  pressed  back  to 


70  TEEATISE    OX    XEEYOUS    DISEASES 

its  fullest  extent  by  a  spring.  At  the  end  of  the  piston  rod  is  a 
flat  disk  which  is  pressed  against  the  skin.  The  physician  then 
presses  against  the  end  of  the  cylinder,  forcing  the  piston  into  the 
barrel,  and  the  amount  of  pressure  made  before  it  is  recognised 
by  the  patient  is  indicated  by  a  scale  on  the  instrument.  In  this 
connection  it  should  be  stated  that  there  is  a  similar  instrument, 
which  is  called  the  algometer,  devised  by  Dr.  Arthur  MacDonald, 
by  which  pain  is  tested  in  a  similar  manner  to  that  of  the  above 
instrument.  Instead  of  the  plain  disk,  however,  a  sharpened  point 
is  forced  upon  the  part  to  be  tested. 

SENSATIONS    OF    MOTION 

It  may  be  necessary-  to  diagnosticate  diseases  of  the  semi- 
circular canals,  the  vestibular  nerve  and  its  terminations,  from 
affections  of  the  cochlear  nerve,  which  latter  is  the  true  nerve 
of  hearing.  Since  the  two  nerves  are  so  closely  approximated  in 
most  deaf  jDersons,  it  will  be  found  that  sensations  of  motion  are 
also  affected  in  them.  So  that  it  is  chiefly  where  the  periphery  of 
the  vestibular  nerve  is  affected,  the  patient  not  being  deaf,  there- 
fore, that  abnormal  sensation  of  motion  are  produced  in  hearing 
individuals.  In  this  test,  deafness  or  not  should,  of  course,  be  first 
determined.  Then  rapidly  rotate  the  table  upon  which  the  patient 
stands,  the  top  of  which  is  placed  upon  a  pivot,  as  suggested  by 
Sanford.  In  health  the  direction  of  rotation  can  be  recognised 
when  the  rate  is  as  low  as  two  degrees  per  second,  or  even  lower. 
In  some  deaf-mutes  the  sense  of  motion  is  entirely  absent.  This 
latter  is  probably  a  reason  why  deaf  people  seldom  get  seasick. 

OCULAR    DISTURBANCES 

In  this  we  examine  for  changes  in  the  optic  nerve,  such  as 
neuritis,  atrophy,  occurring  in  brain  tumour,  meningitis,  etc. ;  also 
for  changes  in  the  retina,  especially  concerned  in  specific  disease 
of  the  nervous  S3'Stem.  Eefractive  errors  are  not  a  part  of  neuro- 
logical examination.  Nystagmus  or  involuntary  oscillation  of  the 
eyes,  usually  bilateral  aud  horizontal,  is  present  iu  affections  of  the 
cerebellum  and  in  dissem-iuated  scleroses.  It  is  irregular  or  rotary 
in  type  in  blind  persons.    N'ystagmus  may  also  be  congenital. 

TJemxanopsia  is  loss  of  one  side  of  the  visual  field,  whereas 
Jiemiopia  refers  to  loss  of  visual  power  in  one-half  of  the  retina. 


SYMPTOMS    AXD    METHODS    OF    EXAMIXATIOX   Tl 

The  latter  term  is  generally  used  in  describing  peripheral  dis- 
turbances, whereas  hemianopsia  is  used  in  the  study  of  brain  dis- 
eases. The  lesion  causing  hemianopsia  is  situated  anywhere  from 
the  cortical  centres  of  vision  in  the  occipital  lol)e  to  the  optic 
chiasm.  In  rare  cases  it  may  be  necessary  to  study  areas  of  ob- 
scuration of  vision,  as  cjuadrants  or  irregular  areas.  Hemianopsia 
may  be  vertical,  horizontal,  bilateral,  binocular,  or  lateral  ho- 
monymous. 

Homonymous  hemianopsia  indicates  blindness  of  the  inner  half 
of  one  field  and  the  outer  half  of  the  other  field  of  vision. 

Amblyopia  indicates  dimness  of  vision. 

Amaurosis  indicates  total  blindness. 

Hemianopsia  can  be  roughly  determined  by  having  the  patient 
look  at  a  fixed  point,  then  by  moving  an  object  from  without  in, 
in  all  portions  of  the  visual  field,  when,  if  it  is  not  present,  the 
moving  object  Avill  be  perceived  at  the  proper  limit.  The  perim- 
eter of  Emerson  is  also  used  by  the  ophthalmologist  to  make  these 
tests. 

Errors  of  refraction  and  exophthalmos  should  also  he  noted. 

Wernicl-e's  liemiopic  pupillary  inaction  consists  in  lack  of  con- 
traction of  the  iris  when  a  ray  of  light  is  thrown  on  the  blinded 
side  of  the  retina.  Since  the  reflex  centre  of  this  arc  is  located 
in  the  primary  optic  centres  in  the  pregeminum  and  pregenie- 
ulum,  if  the  lesion  is  behind  these  centres,  the  reaction  does  not 
occur.  If  the  lesion  is  in  front  of  the  primary  centres,  the  inac- 
tion occurs. 

Colour  Changes. — Occasionally  subnormal  colour  perception 
exists  with  hemianopsia  or  v/ith  sector  defects  of  the  eye.  Con- 
centric restriction  in  the  field  of  vision  and  reversal  of  the  order 
of  colour  field  may  be  present  and  may  be  tested  for  with  colour 
disks  in  the  slide  of  the  perimeter.  Abnormalities  of  the  visual 
fields  may  occur  in  functional  disease;  thus,  in  hysteria  we  may 
have  complete  reversal  of  the  colour  field  with  a  constriction  of  the 
field  of  vision.  The  condition  is  likely  due  to  defect  of  perception 
in  this  disease,  as  described  by  De  Schweinitz  and  J.  K.  Mitchell. 
The  test  for  colour  is  made  by  means  of  coloured  yarns. 

Pupillary  Symptoms. — We  note  under  this  if  the  pupils  are 
dilated,  contracted,  or  irregular;  also  seek  for  abrupt  and  frequent 
changes  in  the  pupil  and  also  for  spasms  or  paralysis  of  accom- 
modation, etc. 


n 


TREATISE   ON   NERVOUS   DISEASES 


Argyll-Hobertson  pupil  is  one  in  Avhicli  there  is  wanting  re- 
sponse to  light,  the  power  of  accommodation  remaining. 

A  phenomenon  called  Jiippus  is  produced  when  the  hand  cov- 
ering the  eye,  directed  towards  the  light,  is  removed,  the  pupil  at 


usu^ 


'SU  A^ 


Pig.  19.— Diagram  of  Visual  Paths.  (Prom  Vialet,  modified.) 
OP.  N.,  Optic  nerve.  OP.  C,  Optic  chiasm.  OP.  T.,  Optic  tract.  OP.  R.,  Optic  ra- 
diations. GEN.,  Genicnlate  body.  THO.,  Optic  thalamus.  C.  QU.,  Corpora 
quadrigemina.  C.  C,  Corpus  callosum.  V.  S.,  Visual  speech  centre.  A.  S.,  Audi- 
tory speech  centre.  M.  S.,  Motor  speech  centre.  A  lesion  at  1  causes  blindness  of 
that  eye ;  at  3,  bi-temporal  hemianopia ;  at  3,  nasal  hemianopia.  Symmetrical 
lesions  at  3  and  3  would  cause  bi-nasal  hemianopia ;  at  4,  hemianopia  of  both  eyes, 
with  hemianopic  pupillary  inaction ;  at  .5  and  6,  hemianopia  of  both  eyes,  pupillary 
reflexes  normal ;  at  7,  amblyopia,  especially  of  opposite  eye  ■,  at  8,  on  left  side,  word- 
blindness. 


SYMPTOMS  AND  METHODS  OF  EXAMINATION  73 

first  contracts^  and  then  slightly  dilates,  and  thus  oscillates  until  it 
settles  to  the  original  size. 

During  the  testing  for  mobility  of  the  iris  the  eye  must  be 
fixed  upon  a  distant  point,  if  not,  the  influence  of  accommodation 
and  convergence  will  prevent  accuracy. 

Hearing. — This  is  tested  by  means  of  a  watch  brought  towards 
the  ear,  the  point  at  which  it  is  first  heard  to  tick  being  recorded. 
The  eye  should  be  closed  when  this  is  being  done.  This  test  shows 
the  extent  of  air  conduction.  Bone  conduction  is  tested  by  using 
watch  or  tuning-fork.  The  patient  being  deaf,  a  tuning-fork 
struck,  then  placed  over  the  mastoid  process  is  heard  better  than  by 
aerial  conduction  in  an  ear  that  is  diseased  in  the  middle  portion. 
Disease  of  the  labyrinth  or  nerve  will,  of  course,  destroy  bone  con- 
duction as  well  as  aerial. 

Galton's  whistle  is  a  piece  of  brass  tubing,  with  an  internal 
diameter  of  less  than  ^  of  an  inch,  into  which  a  plug  can  be  fitted 
and  drawn  in  or  out  at  will.    This  is  used  in  determining  pitch. 

Deafness  is  of  different  degrees.  We  speak  of  this  as  a  person 
being  totally  deaf,  partially  deaf,  or  having  impaired  hearing. 
The  three  terms  indicate  the  degree  of  defect  in  the  order  men- 
tioned. 

Smell. — In  testing  the  efficacy  of  the  olfactory  nerve,  and  in 
distinguishing  acuteness,  we  should  avoid,  first,  the  use  of  any 
irritating  substance,  and,  secondly,  select  pleasant  odours;  thus, 
the  odour  of  violets,  musk,  camphor,  oil  of  cloves,  etc.,  should 
be  placed  upon  cotton  and  applied  to  one  nostril  while  the  other 
one  is  held  closed  at  the  time.  The  loss  of  the  sense  of  smell  may 
be  due  either  to  a  functional  or  an  organic  disease.  Of  the  former, 
hysteria  is  an  example.  Anosmia  is  the  name  given  to  that  condi- 
tion where  there  is  loss  of  the  sense  of  smell.  Fracture  through 
the  ethmoid  may  cause  organic  anosmia.  Hyperosmia  is  increased 
acuity  of  the  sense  of  smell.  Parosmia  is  the  perversion  of  the 
sense  of  smell. 

Taste. — This  is  tested  for  by  means  of  a  sweet  solution,  or  of 
something  sour  or  bitter.  In  making  the  test  the  patient  should 
be  asked  to  protrude  the  toncjne,  the  solution  being  dropped  upon 
one  side  of  the  tongue,  and  the  patient  again  asked  to  record  the 
sensation  before  retracting  the  tongue  into  the  mouth,  otherwise 
the  sensation  will  be  perverted  by  impingement  of  the  test  solution 
upon  adjacent  parts  of  the  mouth.    A  test  should  be  applied  to  the 


74  TKEATISE    OX    XERVOUS    DISEASES 

sides,  back,  tip,  and  middle  of  the  tongue,  according  to  the  part 
desired  to  be  tested,  and  is  indicated  upon  each  half  separately. 

The  sense  of  taste  can  be  tested  electrically  by  an  instrument 
invented  by  Xewman  consisting  of  a  long  stem  carrying  two  wires 
isolated  from  each  other,  at  the  ends  of  which  are  two  little  balls, 
forming  the  poles.  The  current  being  applied,  the  sense  of  taste,  if 
present,  is  readily  perceived  in  a  sapid  and  metallic  sense  of  taste. 
In  order  to  prevent  confusion,  smell,  touch,  or  taste,  the  eyes 
should  be  shut  and  the  nostrils  held  in  difficult  cases.  Ageusia  is 
absence  of  taste.  Hypergeusia  is  increased  sensibility  of  taste. 
Parageusia  is  perversion  of  the  sense  of  taste. 

Reflexes. — Since  these  are  most  important  they  will  be  gone 
over  again  from  a  different  viewpoint.  The  reflexes  are  divided 
into  cutaneous,  deep,  and  visceral,  as  noted  in  a  previous  section. 

Exaggerated  responses  of  skin  reflexes  will  be  produced  if  the 
special  sense  organ  is  in  an  irritated  or  inflamed  condition,  or  if 
they  are  cut  off  from  central  control,  or  if  cerebral  sensory  areas 
are  diseased.  The  lack  of  response  would  indicate  that  the  nerve- 
tracts  in  the  periphery  or  in  the  cord  are  injured,  or  that  the 
special  sense  organs  are  destroyed  or  impaired.  The  skin  reflexes 
have  been  divided  in  accordance  with  the  areas  most  conveniently 
tested,  as  the  supraorhiial,  the  epigastric,  over  the  epigastric  re- 
gion: cremasteric,  brought  out  by  irritation  over  the  inner  part 
of  the  thigh;  the  abdominal,  over  the  sides  of  the  abdomen;  the 
plantar,  obtained  by  irritating  the  sole  of  the  foot.  In  the  trunk 
and  upper  extremities  we  have  the  intercostal,  the  interscapular, 
the  palmar,  the  bicipital,  and  in  the  head  the  conjunctival  and 
pliaryngeal.  The  skin  reflexes  are  very  easily  exhausted  even  in 
very  sensitive  individuals.  Therefore,  the  test  should  be  mad.e 
quickly  and  recorded  at  once  before  the  loss  occurs. 

Deep  Reflexes. — These  deep  reflexes  are  muscle  or  tendon  re- 
flexes. The  knee-jerk  or  patellar  reflex  is  that  produced  by  tap- 
ping the  ligamentum  patella,  which  by  stimulating  contraction  of 
the  erector  femori  group  of  muscles,  produce  extension  of  the  leg. 
The  jerk  is  due,  first,  to  the  direct  stimulation  of  the  muscles, 
and,  secondly,  to  reflex  influences.  The  elbow-jerk  is  produced 
by  tapping  the  triceps  tendon,  the  arm  being  pendant  over  some 
object,  as  the  back  of  a  chair.  Extension  of  the  forearm  occurs. 
The  biceps-jerk  is  produced  upon  striking  the  biceps  tendon  of 
the  arm,  the  member  being  held  in  semi-flexion.     This  produces 


SYMPTOMS    AXD    METHODS    OF    EXAMIXATION^   75 


flexion  of  the  forearm  upon  the  arm.     JerTcs  or  reflexes  can  also 
be  obtained  over  some  of  the  muscles  of  the  neck^  as  well  as  from 


NHIBITING   FIBRES! 
FROM  > 

CEREBRUM.         j 
DISEASE  AFFECTING 
THESE  ALLOWS 
EXAGGERATED  REFLEXES 


[-CORTICAL 
LESIONS. 
SPASTIC 
PARALYSIS 


DISEASE  OF 

MOTOR 
END-PLATES 


SHOWING  THE  MECHANISM  OF  THE  DEEP 
REFLEXES  AND  EXAMPLES  OF  THE  LESIONS 
WHICH  MAY  INCREASE  OR  ABOLISH  THEM 
AS  ILLUSTRATED  BY  THE  KNEE-JERK. 

DOTTED  CIRCLES  =  LESIONS  ABOLISHING 
THE  REFLEXES. 

BLACK  C1RCLES  =  LESI0NS  EXAGGERATING 
THE  REFLEXES. 


Fig.  20. —  Showing  mechanism  of  deep  reflexes ; 
also  the  two  main  types  (spastic  and  flaccid)  of 
paralysis.     (From  Butler's  Diagnostics  ) 


76  TEEATISE    ON    NERVOUS    DISEASES 

the  tendons.  The  reflexes  may  be  exaggerated,  depressed,  or  abol- 
ished in  nervous  diseases.  In  making  a  test  the  part  should  he 
well  suj^ported  and  voluntary  effort  on  part  of  the  patient  avoided. 
The  cliin  or  jaw-jerk  is  that  produced  by  tapping  the  mental  proc- 
ess of  the  inferior  maxillary  bone,  the  mouth  being  held  loosely 
open,  when  contraction  of  the  temporal  muscles  occurs  to  the 
closure  of  the  mouth.  It  is  diminished  in  neurasthenia.  Muscle- 
jerks  are  the  same  as  deep  reflexes  and  are  also  obtained  by  striking 
the  muscle,  when  shortening  occurs.  If  disease  or  an  injur}^  severs 
the  nerve  supplying  the  muscle,  the  tendon  reflex  is  absent,  but 
"  humping  "  from  a  direct  blow  over  the  belly  of  the  muscle  may 
remain  for  a  time. 

Ankle  clonus  is  produced  by  "sudden  flexion  of  the  ankle,  when  a 
rapid  clonic  movement  will  follow  if  the  phenomenon  be  present. 
Paradoxical  contraction  is  the  sudden  contraction  as  of  the  ante- 
rior tibial  muscles,  when  the  said  muscles  are  suddenly  shortened 
by  movement  of  the  extremity.  These  two  reflexes  are  always 
abnormal,  and  indicate  excess  of  irritability  of  an  organic  nature. 

Bulbo-cavernous  reflex  consists  in  sudden  contraction  of  the 
ischial  and  bulbo-cavernous  muscles  caused  by  mechanical  excita- 
tion of  the  glans  penis.  It  is  produced  by  placing  the  left  index 
finger  on  the  bulbous  portion  of  the  penis,  and  with  the  right 
hand  striking,  with  a  piece  of  paper,  the  dorsal  surface  of  the  glans. 
Onanoff  believes  that  its  absence  is  the  sign  of  an  organic  lesion. 
If  the  sexual  function  is  impaired  and  the  reflex  is  present,  the 
disease  is  probably  of  dynamic  origin,  and  favourable  prognosis 
can  be  given.  This  reflex  is  also  styled  virile  reflex  by  Hughes 
of  St.  Louis. 

The  anal  reflex  has  its  centre  in  the  third  sacral  segment. 
It  is  found  increased  in  neurasthenia  and  in  myelitis  high  up, 
but  is  diminished  in  sacral  neuritis  and  posterior  scleroses.    - 

Visceral  Reflexes. — Eye. — The  liglit  reflex  is  produced  by 
throwing  a  ray  of  light  into  the  eye,  when  the  pupil  contracts, 
to  dilate  again  when  the  light  is  removed.  The  accommodation 
reflex  is  brought  about  by  causing  the  patient  to  look  at  a  near 
and  a  far  object.  In  the  former  case  the  pupil  contracts;  in  the 
latter  it  dilates.  One  eye  should  be  covered  in  examining  for  the 
reflex  of  the  pupil.  When  the  light  reflex  is  lost  and  accommo- 
dation remains,  we  have  what  is  known  as  the  Argyll-Robertson 
pupil. 


SYMPTOMS  AXD  METHODS  OF  EXAMINATION  77 

Reflexes  of  the  Bladder,   Rectum,   and  Sexual  Apparatus. — 

Urination  and  defecation  are  reflex  acts  under  control  of  higher 
centres.  If  the  inhihitory  influence  is  removed  and  voluntary 
control  over  the  sphincters  is  lost,  urine  and  faeces  are  expelled 
as  soon  as  bladder  and  rectum  are  full.  Disturbance  of  function 
of  the  pyramidal  tracts  will  bring  about  this  condition.  The 
bladder  walls  may  become  weak,  and  if  the  compressor'  urethrce 
remains  intact  the  bladder  becomes  distended,  and  we  have  in- 
continence of  overflow.  If  any  of  the  components  of  the  reflex 
are  involved,  incontinence  will  occur.  If  the  motor  part  is  dis- 
eased, the  sphincters  are  relaxed.  In  case  of  the  rectum,  if  the 
rectal  sphincter  is  relaxed  it  is  due  to  (as  can  be  shown  by  digital 
examination  here)  disease  of  the  motor  part  of  the  arc.  If  the 
sensory  part  of  the  arc  is  diseased,  the  patient  is  unaware  that  the 
bladder  or  rectum  is  full.  Damage  to  arc  of  genital  functions  may 
bring  about  loss  of  sexual  power  and  desire. 

The  Surface  Temperature. — It  is  desirable  to  note  the  local 
temperature  in  many  diseases,  in  some  of  which  this  symptom  is 
of  special  value,  as  in  cerebral  haemorrhage,  infantile  palsy,  and 
in  the  various  vaso-motor  and  trophic  disturbances.  In  cerebral 
diseases  we  may  find  an  increase  or  a  diminution  over  some  por- 
tion of  the  scalp. 

In  erythromelalgia  the  surface  temperature  is  increased,  espe- 
cially when  the  affected  limb  is  pendant.  This  can  be  detected 
by  a  thermometer,  which  was  first  invented  and  constructed  by 
Seguin. 

The  Mattson's  surface  thermometer  is  an  instrument  consisting 
of  a  coil  containing  the  mercury  and  extending  up  a  tube  at  right 
angles  to  the  coil.    It  is  the  best  instrument  that  we  have  used. 


CHAPTEE    IV 

GENERAL  THERAPEUTICS  AND  PREVENTION  OF  NERV- 
OUS DISEASE  AND  THE  ACQUIRE 2IE NT  OF  NERVOUS 
HEALTH  —  HYDROTHERAPEUTICS  —  MASSAGE  —  ELEC- 
TRICITY —  HYPNOTISM  —  CARE  AND  TREATMENT  IN 
CONVALESCENCE  FROM  FUNCTIONAL  NERVOUS  DIS- 
EASE—CLIMATOLOGY OF  NERVOUS  DISEASE 

TREATMENT  AND  PREVENTION  OF  NERVOUS  DIS- 
EASE AND  THE  ACQUIREMENT  OF  NERVOUS 
HEALTH 

Ix  the  treatment  of  nervous  disease  the  physician  should  at- 
tempt to  relieve  distressing  symptoms,  or  better,  to  secure  an  out- 
and-out  cure,  or  to  prevent  return — prophylaxis  being  always  the 
ideal,  but  which  it  is  difficult  to  inculcate  into  the  minds  of  or 
enforce  upon  people  who  have  not  once  gone  through  suffering. 

General  measures  to  be  instituted  in  the  care  of  nervous  dis- 
ease are,  first  hygiene,  then  exercise,  rest,  diet,  climate,  hydro- 
therapy, massage,  electricity,  external  and  internal  applications 
and  measures,  surgical  procedures,  and  finally,  the  judicious  use  of 
drugs  and  of  other  remedial  measures. 

Hygiene. — To  maintain  normal  nervous  sy.stems  in  the  present 
social  life  led  by  Americans  would  require  extreme  alterations  in 
method  of  living  of  the  majority,  though  gradually  the  cultured 
educated  classes  are  beginning  to  appreciate  this,  and  are  adopt- 
ing more  common-sense  methods  of  living,  which  wise  scientific 
doctors  have  been  advising  for  so  long.  Methods  here  detailed 
are  particularly  applicable  to  the  neuropathic  individual,  but  it 
must  be  remembered  that  the  nervous  predisposition  does  not  start 
de  novo,  and  hence  the  suggestions  to  be  here  made  can  apply  in 
proper  measure  to  all  active  people. 

Thus,  persons  of  neuropathic  stock  should-  not  intermarry. 
Consanguinity  should  be  avoided;  nor  should  intermarriage  take 
place  betweeen,  families  of  highly  nervous  temperaments.  Chil- 
dren should  live  much  in  the  open  air  to  develop  themselves  by 
78 


GENERAL    THERAPEUTICS    AND   PREVENTION     79 

natural  methods  of  physical  exercise,  such  as  walking,  boating, 
horseback-riding.  The  overdoing  of  many  so-called  medical  gym- 
nastic exercises  should  be  prevented.  People  should  be  taught  to 
eat  slowly,  masticate  and  insalivate  thoroughly,  and  to  live  on  a 
wholesome  mixed  diet  of  fats,  carbohydrates,  and  proteids.  Self- 
control  and  obedience  should  be  inculcated  into  children  from  an 
early  age.  This  particularly  prevents  the  development  of  hysteria, 
that  disorder  of  the  emotions.  Systematic  study  and  work  is  essen- 
tial; never  overwork  in  growing  youth.  All  reflex  causes,  such  as 
by  eye-strain,  through  poor  light,  or  errors  in  refraction,  should 
be  looked  to.  Ventilation,  if  poor,  will  have  a  baneful  influence 
through  preventing  proper  oxidation  and  growth  and  nutrition  of 
nerve  and  other  tissues  in  the  economy.  The  occupation  should 
be  carefully  selected  for  the  young ;  overeducation  is  to  be  avoided, 
since  it  brings  about  stress  upon  the  growing  brain  and  its  highest 
function,  the  mind.  Weak  children  should  indeed,  be  especially 
educated  in  accordance  with  their  physical  development  and  nerv- 
ous capacity.  Precocious  children  are  only  more  apt  to  develop 
breakdowns  because  they  do  overwork.  The  queer  or  eccentric 
child  is  the  one,  however,  that  must  be  well  guarded  if  a  nervous 
wreck  is  not  to  develop  at  adolescence.  Mental  overwork  in  them 
should  largely  be  substituted  by  physical  exercise.  Even  this  can 
easily  be  overdone.  Many  people  of  this  stamp  would  make 
excellent  artisans  or  mechanics,  or  even  labourers,  and  enhance 
the  value  of  the  race  by  such  manual  labour  rather  than  by  being 
advised  or  set  to  do  the  work  of  the  mind  such  as  is  compassed 
in  the  professions.  "  Moderation  in  all  things ''  is  an  old  adage 
that  amply  applies  to  prophylaxis  of  nervous  disease.  This  applies 
to  sexual  indulgence  in  adults  in  particular.  Exercise  is  a  very 
valuable  prophylactic  measure  for  them.  Luetic  infection  is  the 
one  prominent  single  misfortune  that  can  happen  to  an  individual; 
for  even  if  treated  to  the  full,  there  still  lurks  remote  toxines 
within  the  blood  which  at  the  degenerative  period  of  life  cause 
neurasthenia,  hysteria,  or  grave  organic  or  suborganic  disease, 
which  seldom  can  be  entirely  relieved.  The  overuse  of  tea,  coffee, 
condiments,  tobacco,  or  alcohol  must  be  remembered  as  causes  of 
various  functional  and  organic  diseases,  such  as  optic  atrophy  or 
chronic  neuritis.  Mental  and  physical  trauma;  poisons,  as  lead 
or  mercury;  or  the  infective  fevers,  are  all  causes  of  various 
nervous  disorders.    Alcoholic  abuse,  it  should  be  repeated,  stands 


80  TEEATISE    ON   NERVOUS   DISEASES 

next  to  syphilis  as  a  cause  of  a  legiori  of  diseases  of  the  nervous 
system.  At  least  eight  hours  of  sleep  should  be  had  in  twenty- 
four  hours  by  every  healthy  man. 

Diet. — As  indicated  above,  nitrogenous  food  should  be  given 
in  abundance  to  the  nervous,  since  there  is  waste  in  them  of  nu- 
clein  and  other  proteid  substances  from  the  nerve-cells.  Fats 
are  next  in  importance;  carbohydrates  least,  and  they  also  fre- 
quently interfere  with  digestion,  since  it  requires  more  caloric,  and 
therefore  nervous  energy  to  oxidize  this  class  of  foodstuffs. 
Water  should  be  drunk  freely  between  meals,  and  even  a  glass  of 
water  at  the  meal  is  a  desideratum,  since  certain  salts  of  food  need 
the  chemical  action  of  water  to  convert  them  into  soluble  chem- 
ical substances.  The  obese  should  not  eat  or  drink  as  freely  as  a 
spare  person.  If  muscular  exercise  is  indulged,  then  the  total 
amount  of  food  should  be  increased.  If  the  patient  is  consti- 
pated, green  vegetables,  farinaceous  foods,  or  an  orange  before 
breakfast  are  valuable  remedial  measures  in  dietary.  The  best 
foods  are  meats — beefsteak  and  fowl;  also  eggs,  fish,  milk,  but- 
termilk, and  cocoa;  stale  bread,  to  which  can  be  added  plenty  of 
butter.  Metal  workers  .should  have  plain  drinks  and  alkaline 
waters.  It  must  be  remembered  that  adults  cannot  take  so  copi- 
ously of  milk  as  children.  The  use  of  alcohol  is  baneful  for  the 
nervous  body.  Some  claim  it  may  increase  capacity  for  work,  but 
I  am  perfectly  sure  this  is  not  the  case.  In  disease  with  tempera- 
ture it  is,  of  course,  of  value. 

"  Generally  nervous  "  still  applies  to  a  class  of  irritable  persons 
anno5^ed  by  trifles,  yet  not  truly  neurasthenic  nor  hysterical.  In 
all  three  of  the  latter  states,  however,  the  patients  can  and  should 
take  large  quantities  of  proteid  food,  to  which  should  be  added 
the  heat-giving  foodstuff  fats  as  much  as  can  be  easily  digested, 
since  these  patients  always  complain  of  being  cold  or  chilly  at  the 
slightest  exposure.  Some  nervous  persons  cannot  take  sweets  with- 
out producing  headache,  rheumatic  pains,  or  disorders  of  digestion, 
due  to  the  fermentation  produced  and  acid  condition  of  the  blood 
(uricacidsemia)  following.  In  such  people  the  diet  should  ex- 
clude carbohydrates  and  include  meats,  fish,  oils,  as  cod-liver  or 
olive;  also  cream,  milk,  oysters,  and  even  pork.  Spinach  is  an 
excellent  food  for  the  neurotic,  since  it  is  laxative  and  contains 
a  goodly  proportion  of  iron.  The  white  of  an  egg  added  to  beef- 
tea,  to  which  can  be  placed  in  addition  some  form  of  peptonoids. 


GENERAL  THERAPEUTICS  AND  PREVENTION  81 

is  very  nutritious.  Besides  the  stale  bread  indicated,  in  which  fer- 
mentation is  complete  and  the  individual  elements  better  dis- 
persed, the  nervous  person  can  use  the  special  fornif?  of  breads  in 
which  the  starch  has  largely  been  removed.  These  give  the  gastric 
content  a  release  from  overtaxation  in  digestion  of  the  carbo- 
hydrates. Practically,  however,  the  patient  cannot  take  these 
breads  for  any  length  of  time,  since  they  are  unpalatable. 

If  a  rigid  diet  is  desirable  make  it  as  follows:  Milk,  oysters, 
butter,  eggs,  raw  or  soft,  cocoa,  graham  or  gluten  bread,  beef, 
fowl,  mutton,  lamb,  or  fish.  Among  _  vegetables  spinach,  lettuce, 
string-beans,  Brussels  sprouts,  or  stewed  fruits  are  the  best.  The 
neurotic  person,  from  the  subjective  craving  of  nature  (boulimia), 
is  liable  to  eat  too  much.  Hence  this  should  be  guarded  against, 
since  overloading  the  stomach  in  them  may  cause  gastrectasia, 
an  added  mechanical  cause  for  indigestion.  Tea^,  coffee,  and  alco- 
hol are  baneful  in  effect  upon  the  franhly  nervous  person.  Over- 
use of  the  alkaline  mineral  waters  should  be  avoided,  since  disturb- 
ance of  the  normal  acid  secretion  of  the  stomach  will  be  brought 
about  and  add  to  distress.  Three  to  four  pints  of  plain  water 
should  be  drunk  per  diem.  Dryness  of  or  desiccated  nervous 
systems  cause  instability  of  function. 

Exercise. — The  value  of  exercise,  if  taken  out  of  doors,  as  in 
rowing  or  horseback-riding,  where  the  mind  cannot  run  in  special 
grooves,  is  a  certain  preventive  of  nervousness  beyond  calculation. 
The  exercise  should  not  be  violent  in  brain-workers — i.  e.,  they 
should  not  go  into  severe  athletic  training.  Even  the  majority  of 
youth  or  of  adults  cannot  do  well  both  physical  training  and  men- 
tal work  of  the  highest  sort.  Nervous  persons  need  exercise  asso- 
ciated with  interest  to  the  mind;  hence  the  individuality  of  the 
pleasure  of  one  person  as  compared  to  another  must  be  borne  in 
mind,  and  not  too  strict  rules  laid  down  by  the  physician.  Gym- 
nastic exercises  indoors,  as  a  rule,  do  little  good  from  the  fact 
of  the  monotony  of  the  procedure  entailed.  The  mind  must  be 
properly  exhilarated  with  it  all.  Walking  is  a  valuable  form  of 
exercise,  since  it  is  moderate,  and  movements  of  the  arms  bring 
into  play  the  muscles  of  the  chest.  Horseback-riding  is  the  very 
best  exercise  the  nervous  patient  can  take,  since  it  carries  the  pa- 
tient out  into  the  fresh  air,  expands  the  chest,  gives  free  use  of  the 
arms,  and  does  not  require  the  extremes  of  exertion  as  with  other 
forms  of  exercise.     Then  the  spinal  cord  is  not  drawn  upon  so 


82  TREATISE    ON    NERVOUS    DISEASES 

heavily  in  expending  the  little  reserve  of  nervous  energy  the  neu- 
rotic holds  claim  to  as  does  walking^,  bicycling,  golfing,  ,and  the 
like.  Exercise  should  be  cut  down  much  after  the  degenerative 
period  of  age  has  set  in  (i.  e.,  after  forty)  if  a  person  wishes  to 
live  a  long  life. 

HYDROTHERAPEUTICS    IN    NERVOUS    DISEASES 

This  important  adjunct  to  neurological  care  of  the  many  cases 
coming  under  our  observation  is  important  for  the  physician  and 
nurse  to  know  well.  The  proper  external  use  of  water  aids  much 
the  general  treatment  of  nervous  disease.  The  effect  of  water  be- 
sides the  hygienic  place,  and  often  the  favourable  mental  influence 
upon  the  patient,  as  in  eases  where  neurasthenic  and  hypochondri- 
acal phobias  exist,  is  mainly  due  to  reflex  action  upon  the  nervous 
system.  The  "  reflex "  arcs  so  patent  in  the  symptomatology  of 
organic  diseases  of  the  central  and  peripheral  nervous  systems  we 
are  apt  to  let  pass  by  when  we  are  earing  for  the  so-called  func- 
tional diseases ;  whereas  in  them  can  be  found  the  reflex  guide-posts 
to  the  treatment  of  the  case  that  may  be  cured.  In  organic  dis- 
ease, it  must  be  re-enforced,  we  have  the  grosser  expressions  of 
what  scientific  clinical  medicine  behooves  us  to -search  for  in  the 
very  incipiency.  And  it  is  here  in  place  to.  say  that  the  scientific 
physician  will  ever  be  the  leader  in  progress,  albeit  medicine,  for 
the  very  reason  that  we  deal  with  life,  can  never  be  a  true  science. 
Much  of  the  treatment  at  Carlsbad  is  scientific ;  a  great  deal  of  the 
good  results  are  from  the  engendered  mental  buoyancy  which  we 
must  recognise.  With, these  well-balanced  therapeutic  ideas  kept 
perfectly  clear  in  mind,  the  physician  of  largest  attainments  will 
use  bathing  freely  more  and  more  conscientiously  until  he  learns 
the  true  value  of  the  bath  in  its  physical  effects  on  the  body,  sick 
or  well. 

Turkish  Bathing. — The  origin  of  Turkish  bathing,  so  peculiar- 
ly associated  with  the  religious  rites  of  the  oriental  people,  is  quite 
as  much  in  nubibus  as  is  the  origin  of  language.  The  effects  of 
dry  heat  are  finally  to  stimulate  hypergemia  of  the  surface  of  the 
body,  to  cause  hypercaloria  and  hyperhydrosis.  As  the  heart  is 
stimulated  by  increase  of  temperature,  that  organ  must  be  very 
competent  before  a  patient  is  relegated  to  this  initiative  step  of 
the  Turkish  bath.  Indeed  the  heart  should  be  toned  up  by  digi- 
talin,  strychnine,  or  strophanthus  when  there  is  the  suspicion  of 


HYDEOTHEEAPEITTICS  83 

cardiac  weakness.  A  patient  with  pronounced  valvular  disease 
should  be  prohibited  from  Turkish  bathing.  Persons  suffer- 
ing from  obesity  or  interstitial  nephritis  may  be  greatly  alleviated 
of  distressing  subjective  phenomena  of  vertigo,  headache,  and  de- 
pression by  judicious  use  of  Turkish  baths.  This  beneficial  effect 
must  be  due  to  elimination  of  toxines  always  retained  in  such 
cases. 

In  anhydrosis,  as  in  myxoedema,  or  in  cases  of  atrophic  dry 
skin  I  have  so  often  seen  in  women  at  the  climacteric  suffering 
from  general  nervousness,  Turkish  bathing  does  a  great  good.  In 
cases  of  neurasthenia  terminalis  I  have  seen  much  improvement 
through  this  form  of  bathing. 

Hystero-neurasthenia  in  persons  of  gouty  diathesis,  on  the 
other  hand,  are  not  benefited  at  all  by  the  Turkish  or  Eussian 
baths. 

Details  of  the  Turkish  Bath. — Like  the  massage  we  use  in 
America,  which  is  the  resultant  of  selection  from  the  best  methods, 
the  Turkish  bath  is  modified  as  we  use  it  for  best  therapeutic 
results.  The  patient  should  have  at  least  two  hours  to  give  to  the 
bath.  This  will  allow  amply  for  the  one  and  three-quarter  hours 
which  should  practically  be  the  time  consumed  in  the  procedure. 
The  patient  is  at  first  sent  to  the  dry  hot-air  room,  where  he  sits 
in  a  reclining  chair,  keeping  perfectly  quiet  and  relaxed.  If  he 
reacts  favourably,  beads  of  sweat  will  soon  begin  to  come  to  the 
surface  of  the  body,  which  is  always  a  favourable  aspect.  Should 
the  patient  complain  of  sense  of  faintness,  the  application  of  cold 
cloths  to  the  head  by  the  attendant  is  directed;  also  the  drinking 
of  cool  water  will  do  much  to  relieve  this  symptom  and  to  hasten 
hydrosis.  As  before  stated,  the  patient  should  be  allowed  to  re- 
main som.e  fifteen  or  twenty  minutes.  The  temperature  of  the 
room  is  kept  up  by  means  of  hot  water  to  the  average  of  153° 
F.  In  cases  of  obesity,  the  patient  may  next  be  taken  to  the 
hotter  room  adjacent,  the  temperature  being  as  high  as  175°  F. 
The  attendant  must  constantly  observe  the  case  taking  an  initial 
bath  in  order  to  avoid  any  ill  effects  of  idiosyncrasy.  The  patient 
is  next  taken  to  the  ruihing  room  in  moderate  temperature  and 
placed  upon  a  marble  slab  on  his  back,  with  his  head  and  heels 
protected  by  cushions  or  sponges. 

He  is  then  given  a  thorough  surface  massage  by  the  attendant, 
the  general  movement  being  from  periphery  to  the  trunk.  With 
6 


84  TREATISE    OK"   NERVOUS    DISEASES 

this  there  is  a  series  of  slapping  motions  with  the  palms  of  the 
hands,  Avhich  greatly  stimulates  the  circulation.  The  back  is  then 
treated  in  the  same  fashion  after  the  patient  is  placed  in  the 
p^rone  j)osition.  The  water  from  a  hose  at  about  the  tempera- 
ture of  105°  F.  is  frequently  deluged  upon  the  subject  with  some 
considerable  force  during  the  manipulations.  He  is  finally 
"  soajDed  over ''  thoroughly  and  again  "  washed  down ''  when  he 
is  prepared  to  enter  the  steam-bath.  Then  the  "  shower  "  is  had, 
or  he  takes  the  "plunge."'  in  the  bath,  at  the  discretion  of  the 
physician. 

In  the  steam-hath  lies  the  modification  and  Mending  of  the 
Turkish  and  Eussian  baths  used  to-day.  The  patient  enters  the 
door  and  quickly  proceeds  to  the  opposite  side  of  the  room,  where 
he  sits  on  the  marble  slab  quietly  for  about  five  minutes;  this  is 
likely  to  be  the  most  discomforting  part  of  the  entire  procedure, 
and  the  patient  should  be  carefully  watched  by  the  attendant  in  the 
first  entrance,  for  there  occasionally  comes  a  sense  of  suffocation, 
which  is  more  a  mental  symptom  than  that  it'is  due  to  lack  of  oxy- 
genation of  the  blood.  Otherwise  at  this  stage  there  is  a  comfort- 
able feeling,  the  sweat  seeming  to  pour  from  the  individual,  which, 
in  reality,  is  not  so,  but  is  due  to  condensation  of  vapour  upon  the 
body.  The  temperature  of  the  body  is  actually  reduced  by  this  part 
of  the  bath,  and  this  is  the  only  reason  why  the  vapour  part  of  the 
bath  should  be  so  short. 

The  slioiver-hath  should  be  substituted  in  all  cases  of  first  treat- 
ment in  order  to  gain  the  confidence  of  the  patient  in  the  rather 
shocking  changes.  The  shower-bath  is  administered  by  a  series 
of  sprays  tempered  to  the  patient  pliysically,  and  it  is  essential 
that  the  water  should  pour  in  these  fine  streamlets  upon  the 
head  as  well  as  the  rest  of  the  body,  else  there  may  be  a  tendency 
to  congestion  of  the  brain  and  its  membranes.  Temperature 
should  range  from  65°  to  85°  F.  If  the  plunge  is  taken,  the 
patient  should  immediately  immerse  himself  in  the  pool.  A 
good  way  to  do  this  is  by  diving,  if  he  is  familiar  with  the  water. 
He  should  remain  in  the  water  three  or  four  minutes,  the  aver- 
age temperature  being  65°  F.  The  patient  is  next  dried 
and  rubbed  in  the  standing  posture  by  the  attendant.  He  is 
then  wrapped  in  a  sheet  and  blanket  and  placed  upon  a  couch 
or  bed,  to  lie  quietly  for  at  least  half  an  hour,  sleep  usually 
followinff. 


HYDROTHEEAPEUTICS  85 

HYDROTHERAPEVTICS-Gontimied 

Water  may  be  used  either  a,s  a  tonic  or  as  a  sedative. 

As  a  tonic  we  employ  cold  plunges,  shower-baths,  varioiis  forms 
of  douches,  as  Charcot's  and  the  Scottish  cold  sitz-bath,  salt  baths, 
either  sea  or  artificial,  and  short  cold  packs.  These  all  have  a 
stimulating  and  tonic  effect.  In  giving  them,  especially  to  weak 
people,  it  is  best  to  begin  with  warm  water  and  gradually  lower  the 
temperature.  Showers  and  douches  are  the  most  stimulating.  A 
reaction  should  always  be  obtained  by  vigorous  rubbing  afterward. 

For  the  cold  plunge,  the  patient  immerses  himself  in  the  bath 
of  water  at  a  temperature  of  60 '^  to  70°  F.,  and  at  once  emerges. 
He  should  then  be  rubbed  vigorously. 

The  shower-  or  rain-hath  consists  in  allowing  water  to  fall  on 
the  body  from  a  height  for  one  or  two  minutes  while  the  feet  are 
in  warm  water.  Friction  of  the  body  should  be  kept  up  during 
this  process. 

A  Charcot  douche  is  given  by  directing  a  solid  stream  of  water 
with  force  upon  the  back  of  the  patient. 

By  the  Scottish  douche  we  mean  alternating  a  cold  douche  with 
a  warm  or  hot  one. 

Cold  pacJcs  are  given  by  wringing  a  sheet  out  in  cold  water, 
wrapping  about  the  patient  for  a  few  moments,  when  it  is  re- 
moved and  the  patient  put  to  bed  and  rubbed. 

An  artificial  salt  hath  may  be  made  by  putting  25  pounds  of 
salt  (NaCl)  in  30  gallons  of  water  (2  per  cent).  It  may  be  warm 
or  cold. 

To  obtain  sedative  effects  we  may  use  the  lukewarm  bath,  wet 
pack,  hot  sitz-bath,  hot  compresses,  and  drip-sheet. 

The  lukewarni  hath  is  given  at  a  temperature  of  95°  to  98° 
F.  for  ten  to  twenty  minutes. 

To  give  a  wet  pack,  spread  a  large,  thick  blanket  upon  the 
bed ;  upon  this  is  laid  a  sheet  wrung  out  in  water  at  a  temperature 
of  40°  to  60°  F.  The  nude  patient  lies  upon  this  and  the 
sheet  is  wrapped  smoothly  about  him,  not  including  the  head  and 
feet.  The  sheet  must  be  carried  between  the  legs  and  brought 
evenly  in  contact  with  the  body.  The  blanket  is  then  folded  over 
him,  with  others  added  if  desired.  Hot-water  bottles  may  be 
placed  at  the  feet  and  cold  compresses  to  the  head.  The  patient 
lies  in  this  for  half  an  hour,  and  is  then  thoroughly  rubbed. 


86  TREATISE    OX    XERVOUS    DISEASES 

The  Drip-Sheet. — Have  a  basin  of  water  at  65°  F.  Put  in  tlie 
basin  a  sheet.  The  patient  stands  in  comfortably  hot  water.  Have 
ready  a  large  soft  towel  and  iced  water.  Wring  out  the  towel  in  this 
and  wrap  it  around  tjie  head  and  back  of  the  neck.  Standing  in 
front  of  the  patient,  the  sheet  is  seized  by  the  two  corners  and 
thrown  about  the  patient,  who  holds  it  at  the  neck.  It  is  then 
smoothed  out  over  the  body;  next  loosened,  dropped,  and  the  pa- 
tient is  instructed  to  lie  down  on  a  blanket,  which  is  wrapped 
about  him.  Dry  thoroughly  with  coarse  towels,  wrap  in  a  dry 
blanket  for  a  time,  then  put  to  bed.  The  water  should  be  grad- 
ually cooled  day  by  day  until  it  is  55°  F. 

The  bath,  pack,  and  drip-sheet  are  valuable  remedies  for  in- 
somnia. 

A  liot  sitz-hath  consists  of  water  at  a  temperature  of  100°  to 
125°  P.    In  this  the  patient  sits  from  twenty  to  thirty  minutes. 

Hot  compresses  are  often  used  for  the  relief  of  local  pains  and 
congestions. 

MASSAGE 

Massage  has  been  used  as  a  therapeutic  agent  in  more  or  less 
crude  fashion  for  centuries. 

The  wrestling  matches  of  the  Greeks  left  many  a  lame  back  or 
joint  which  their  rubbers  dissipated  by  manipulations.  We  all 
know,  too,  the  uses  of  rubbing  in  alleviating  the  sprains  and  bruises 
of  our  army  of  college  athletes. 

By  greater  refinement  in  the  modus  opera?idi  of  massage,  and 
by  very  careful  analysis  of  the  effects  to  be  obtained  by  each  indi- 
vidual movement,  this  useful  adjunct  has  been  in  recent  years 
placed  on  a  much  higher  plane  in  the  therapeutic  arts;  indeed,  in 
some  instances,  in  expert  hands  it  has  almost  amounted  to  a  sci- 
entific basis. 

Schools  of  massage  have  been  established  where  lectures  are 
given  in  the  larger  cities  of  this  country,  also  thorough  practical 
work  is  obtained  during  several  months'  course  required  to  become 
experienced  in  rubbing.  At  the  end  of  this  time  an  examination 
is  had,  when  a  certificate  is  given  entitling  the  holder  to  recogni- 
tion by  the  phj'sician.  Then  a  course  in  electricity  is  added  to 
complete  the  training  of  one  who  chooses  the  vocation  of  mas- 
seur or  masseuse.  The  two  (massage  and  electricity)  go  so 
completely  hand  in  hand  in  the  treatment  of  the  nervous  mal- 


MASSAGE  87 

adies,  where  they  are  chiefly  of  value,  that  it  is  necessary  to  he 
able  to  administer  either  one  or  both  under  the  direction  of  the 
medical  man. 

Notably  in  American  schools  very  good  training  is  given,  but 
also  abroad,  especially  in  Germany  and  Sweden,  in  which  latter 
country  the  series  of  movements  bearing  the  name  of  Swedish 
are  perhaps  best  known  in  a  general  way.  In  America  all  these 
very  intricate  movements  have  been  somewhat  modified ;  and  while 
the  general  tendency  is  towards  definite  ends,  yet  the  extremely 
rigid  mechanical  side  of  massage  is  largely  done  away  with,  and 
we  have  a  more  perfect  system,  much  better  suited  to  the  delicate 
human  organism. 

The  Five  Sets  of  Movements  of  Massage. — 1.  Effleurage  is  the 
gentle  surface  stroking  of  the  part  which  quietly  starts  the  cir- 
culation before  the  more  vigorous. 

2.  Friction  is  then  begiin.  This  latter  consists  in  a  firmer 
and  deeper  pressure-rub  than  the  preceding  movement. 

3.  Petrissage,  which  is  a  very  deep  kneading  of  the  part  and 
completes  what  has  been  begun  by  1  and  3.  It  is  essential  in 
petrissage  to  hold  firmly  to  the  skin  and  to  make  this  rub  the 
subcutaneous  tissues,  while  the  last  in  turn  presses  the  muscles, 
and  so  on  until  the  soft  parts  are  so  manipulated,  squeezed  against 
the  bones  of  the  patient,  that  a  veritable  pushing  on  all  of  the 
liquids  (blood  and  lymph)  takes  place;  also,  indeed,  of  some  of 
the  semi-solids,  which  are  urged  to  disintegration  and  their  ulti- 
mate particles  swept  on  in  the  hurried  circulation,  to  be  oxidized 
or  converted  into  energy,  or  to  be  excreted,  instead  of  remaining 
in  the  body  as  sources  of  irritation  in  the  form  of  what  we  •  call 
leucomaines. 

4.  After  this  thorough  application  a  movement,  not  so  very 
essential,  is  yet  quite  often  used  as  a  final  stimulator  of  the  circu- 
lation where  it  is  extremely  sluggish.  It  consists  of  tapotement 
or  tapping  in  a  rapid  vibratory  manner  with  the  balls  of  the 
fingers  of  one  or  both  hands  held  gently  closed,  similar  to  the 
position  of  holding  a  pen. 

5.  Next  and  last  comes  effleurage  again,  by  which  the  harder 
rubbing  now  reached  shades  ofl'  to  less  vigorous  frictions.  These 
are  soothing  to  the  part  and  to  the  patient  generally,  while  they 
also  equalize  the  blood  circulating  in  the  superficial  tissues.  Then 
the  member  is  immediately  covered  with  a  light  woollen  garment, 


88      TREATISE  ON  NERVOUS  DISEASES 

and  when  the  entire  body  is  so  manipulated  the  patient  rests  for 
an  hour. 

Modified  Swedish  movements,  passive  then  active  {without  and 
with  muscular  resistance  of  the  patient),  are  often  instituted  after 
a  course  of  general  massage  of  some  weeks'  duration.  We  are 
now  speaking  of  general  rubbing  or  applying  the  art  to  the  entire 
body,  as  in  cases  of  neurasthenia,  where  partial  or  the  complete 
"  rest  cure  "  is  being  systematically  carried  out. 

How  to  "  Rub  "  a  Patient. — First  the  subject  is  required  to 
thoroughly  relax  all  muscles;  then  he  is  placed  on  the  right  side, 
and  the  manipulations  are  begun  on  the  left  foot,  toes,  ankle, 
thigh,  hip,  and  buttock  in  turn,  using  all  the  fi^e  movements  de- 
scribed over  each  part,  varying  the  time  and  duration  of  each  in 
proportion  to  the  size,  rigidity,  and  amount  of  muscle  or  other 
soft  tissues  present.  The  patient  is  then  asked  to  turn  towards 
the  opposite  side,  and  the  right  foot,  leg,  thigh,  and  buttock  are 
rubbed  in  the  same  thorough  fashion. 

Gradually  one  set  of  movements  dovetail  into  the  other,  and 
the  patient's  extremity  becomes  almost  a  part  of  the  rubber,  as  does 
the  dough  of  the  housewife;  and  yet  you  note  that  by  the  time 
the  limb  is  finished  every  nook  and  cranny  has  been  gone  over, 
leaving  a  beautiful  glow  of  the  surface  in  evidence  of  the  vigour 
set  up  in  the  circulation  of  the  blood. 

Next  the  left  fingers,  forearm,  arm,  and  shoulder  are  first 
given  the  long  sweeping  efileurage,  followed  again  by  the  rest  of  the 
detailed  movements  described;  but  the  eye  has  to  follow  quickly 
to  appreciate  the  rapid  changes,  so  much  a  part  of  the  manipu- 
lator does  the  patient  become.  Four  or  five  minutes  will  suffice, 
and  then  the  right  arm  is  taken  up.  After  this  we  request  the 
patient  to  lie  on  the  abdomen  with  a  pillow  placed  under  for  better 
resistance.  The  long  series  of  strokings  down  the  vertebral  gutters 
made  alternately  with  the  fingers  of  each  hand  spread  on  either 
side  of  the  spinous  processes.  Then  comes  a  series  of  circular 
frictions  down  each  recti  group  with  one  hand,  then  a  spreading 
movement  from  the  spines  outward  with  the  balls  of  both  thumbs ; 
next  a  firmer  petrissage  with  both  hands,  followed  by  that  motion 
with  the  palms  of  both  hands  alternately  run  down  either  side  of 
the  spinal  column,  giving  a  delightful  sensation,  while  the  final 
efileurage  finishes  and  the  patient  is  requested  to  turn  on  the  broad 
of  the  back,  the  pillow  being  removed. 


MASSAGE  89 

The  chest  movements  consist  principally  of  two :  a  firm  strok- 
ing, following  the  ribs  from  the  sternum  out  and  down,  and  of 
firmer  petrissage,  in  which  the  balls  of  both  thumbs  play  an  im- 
portant role,  and  can  be  so  dextrously  done  as  to  be  not  at  all 
painful,  which  occasionally  happens  with  the  beginner. 

The  abdomen  is  rubbed  as  follows  (this  is  very  important  and 
difficult  to  acquire)  :  the  thighs  are  flexed  on  the  abdomen  and 
legs  on  the  thighs  in  order  to  relax  the  anterior  abdominal  walls. 
The  effieurage  is  simple  enough,  but  it  requires  tact  to  knead  thor- 
oughly without  tickling.  Begin  this  over  the  small  intestine  and 
work  with  both  hands  in  a  "  spanning  "-like  manner.  Then  start 
at  the  caput  coli  and  work  along  the  ascending  transverse  and 
descending  coli,  one  hand  following  the  other  in  rotary  motions. 
Again  effieurage  follows,  and,  as  pointed  out  above,  if  constipation 
is  an  indication  to  be  met,  that  series  of  rapid  vibrations  described 
will  aid  much  towards  the  cure.  As  a  rule,  the  face,  head,  and  neck 
are  not  rubbed  in  ordinary  work.  Where  especially  requested,  it  is 
given  by  a  series  of  strokings  and  kneading  movements  in  the 
direction  of  the  venous  circulation.  It  should  be  stated  that  in 
all  movements  the  greater  pressure  should  be  from  the  periphery 
to  the  heart — i.  e.,  centripetal  in  character.  The  patient  is  now 
allowed  to  have  a  quiet  sleep. 

The  salient  points  of  massage  are  for  the  masseur  to  keep  his 
hands  soft,  clean,  dry,  and  warm. 

A  general  rub  should  last  from  one  half  to  one  hour,  preferably 
about  10  A.  M.,  or  at  bedtime.  If  electricity  is  used,  give  it  at  the 
opposite  hour.  The  patient  should  rest  at  least  three-quarters  of 
an  hour  afterward.  In  orthopjedie  work  a  maxim  obtains — viz., 
"  to  tighten  a  loose  joint  rub  easy,  to  loosen  a  firmly  fixed  joint 
rub  hard  and  deep."  The  relation  of  gymnastics  to  massage 
we  have  only  time  to  hint  at;  suffice  it  to  say  they  are  closely 
allied,  and  the  former  are  perhaps  of  greatest  value  in  lateral 
curvature  of  the  spine  and  in  aiding  chest  expansion  in  lung  dis- 
ease. These  regulated  movements  should  also  be  under  observation 
of  the  physician. 

It  has  been  proved  that  the  renewal  of  the  epithelium  of  the 
alimentary  tract  is  made  more  active  under  massage,  and  that  it 
stimulates  peristalsis.  Blood-pressure  rises  after  massage,  and 
Dr.  J.  K.  Mitchell's  investigation  ^  shows  that  the  blood  elements 


*  American  Journal  of  the  Medical  Sciences,  May,  1893. 


90  TREATISE    OX    XEEVOUS    DISEASES 

are  put  into  more  vigorous  circulation  during  and  after  this  treat- 
ment. Massage  is  of  great  value  for  the  surgeon  in  getting  rid  of 
exudates  about  old  fractures. 

As  to  the  matter  of  technique — of  course  some  become  more 
skilled  than  others,  but  any  person  using  tact  and  practice  will 
learn  to  rub  well.  The  therapeutic  results  obtained  from  massage 
we  have  not  time  to  consider  further,  except  to  mention  the  very 
frequent  relief  of  neuralgia  by  its  careful  use. 

Contra-indication  to  Massage. — It  .should  not  be  administered 
for  an  hour  after  a  meal.  Fever  is  a  contra-indication  to  massage. 
Enlarged  and  thrombosed  veins  should  not  be  rubbed,  else  a  great 
risk  of  setting  up  a  local  active  inflammation  ensues,  or  that  par- 
ticles f emboli)  may  be  carried  on  to  some  important  organ,  as 
the  brain,  causing  paralysis  or  other  serious  results.  Tumours, 
especially  malignant  ones,  should  not  be  manipulated  for  fear  of 
exciting  them  to  more  rapid  growth  and  metastasis.  If  massage 
is  extremely  irritating  after  a  fair  trial  it  should  be  discontinued. 
There  will  occasionally  be  found  one  in  fifty  who  is  made  worse 
by  rubbing.  In  these  persons  we  must  resort  to  g}^mnastics  alone 
or  to  electricity.  The  pregnant  woman  should  not  be  rubbed  about 
the  abdomen;  and  it  is  advisable  to  abstajn  from  abdominal  mas- 
sage during  menstruation,  also  in  any  case  of  acute  pelvic  disease. 
Bimanual  pelvic  massage  may  be  of  value  in  chronic  ca.ses  with 
fixation  of  the  uterus  from  old  adhesion.^ 

MUSCULAR    MOVEMENTS 

Eegular  muscular  movemenis,  according  to  a  fixed  schedule,  as 
first  used  by  Weir  Mitchell,  but  since  elaborated  by  Fraenkel,  are 
of  value  in  the  treatment  of  muscular  inco-ordination.  The  exer- 
cises should  be  performed  with  care  and  precision  twice  daily.' 

The  following  schedule,  based  upon  that  of  Fraenkel  -  and 
Hirshberg.  is  recommended  by  Dana  : 

Exercises  for  the  Hands  and  Feet. — 1.  Sit  in  front  of  a  table; 
place  the  hand  upon  it,  then  elevate  each  finger  as  far  as  pos.sible. 
Then  raising  the  hand  slightly,  extend  and  then  flex  each  finger 

'  For  more  detailed  and  exhaustive  stiiLly  the  works  of  William  ]\riirrel, 
M.  D.,  F.  R.  C.  B.,  on  Masso-therapeutics.  1890.  and  of  Emil  Kleen,  M.  D., 
Handljook  of  Massage,  are  recommended. 

2  The  Treatment  of  Tabetic  Ataxia,  etc.,  1903. 


MUSCULAE    MOVEMENTS  .        91 

and  thumb  as  far  as  possible.     Do  this  with  the  right,  then  with 
the  left.    Eepeat  once. 

2.  With  the  hand  extended  on  the  table,  abduct  the  thumb 
and  then  each  finger  separately  as  far  as  possible.  Repeat  three 
times. 

3.  Touch  with  the  end  of  the  thumb  each  finger-tip  sepa- 
rately and  exactly.  Then  touch  the  middle  of  each  phalanx  of 
each  of  the  four  fingers  with  the  tip  of  the  thumb.  Eepeat  three 
times. 

4.  Place  the  hand  in  the  position  of  piano-playing  and  elevate 
the  thumb  and  fingers  in  succession,  bringing  them  down  again, 
as  in  striking  the  keys  of  the  piano.  Do  this  twenty  times  with 
the  right  hand,  and  the  same  with  the  left. 

5.  Sit  at  a  table  with  a  large  sheet  of  paper  and  pencil.  Make 
four  dots  in  the  four  corners  of  the  paper  and  one  in  the  centre. 
Draw  lines  from  corner  dots  to  centre  dot  with  the  right  hand; 
same  with  the  left. 

6.  Draw  another  set  of  lines  parallel  to  the  first  with  the  right 
hand ;  same  with  the  left. 

7.  Throw  ten  pennies  upon  the  paper.  Pick  them  up  and  place 
them  in  a  single  pile  with  the  right  hand,  then  with  the  left.  Ee- 
peat twice. 

8.  Spread  the  pennies  about  on  the  table.  Touch  each  one 
slowly  and  exactly  with  the  forefinger  of  the  right  hand,  then 
with  the  forefinger  of  the  left.         - 

9.  Place  an  ordinary  solitaire  board  on  the  table,  with  the 
marbles  in  the  groove  around  the  holes.  Put  the  marbles  in  their 
places  with  the  right  hand ;  same  with  the  left  hand.  Patient  may, 
with  advantage,  practise  the  game  for  the  purpose  of  steadying 
his  hands. 

10.  Take  an  ordinary  fox-and-geese  board  with  holes  and  pegs, 
and  beginning  at  one  corner  place  the  pegs  in  the  holes,  one  after 
the  other,  using  first  the  right  hand  and  then  the  left. 

Exercises  for  the  Body  and  Lower  Limbs. — 1.  Sit  in  a  chair. 
Else  slowly  to  the  erect  position  without  help  from  .cane  or  arms 
of  chair.     Sit  down  slowly  in  the  samie  way.    Eepeat  once. 

2.  Stand  with  cane,  feet  together;  advance  the  left  foot  and 
return  it;  same  with  the  right.     Eepeat  three  times. 

3.  Walk  ten  steps  with  cane,  slowly.  Walk  backward  five  steps 
with  cane,  slowly. 


93  TREATISE    ON    NERVOUS    DISEASES 

4.  Stand  without  cane,  feet  a  little  spread  out,  hands  on  hips. 
In  this  position  flex  the  knees,  and  stoop  slowly  down  as  far  as 
possible ;  rise  slowlj^    Repeat  twice. 

5.  Stand  erect,  carry  left  foot  behind,  and  bring  it  back  to  its 
.place;  the  same  with  the  right.     Repeat  three  times. 

6.  Walk  twenty  steps,  as  in  Exercise  No.  3;  then  walk  back- 
ward five  steps. 

7.  Repeat  No.  3  without  cane. 

8.  Stand  without  cane,  heels  together,  hands  on  hips.  Stand 
in  this  way  until  you  can  count  twenty.  Increase  the  duration 
each  day  by  five,  until  you  can  stand  in  this  way  while  one  hundred 
is  being  counted. 

9.  Stand  without  cane,  feet  spread  apart;  raise  the  arms  up 
from  the  sides  until  they  meet  above  the  head.  Repeat  this  three 
times.  With  the  arms  raised  above  the  head,  carry  them  forward 
and  downward,  bending  with  the  body  until  the  tips  of  the  fingers 
come  as  near  as  they  can  be  safely  carried. 

10.  Stand  without  cane,  feet  spread  apart,  hands  on  hips ;  flex 
the  trunk  forward,  then  to  the  left,  then  backward,  then  to  the 
right,  making  a  circle  with  the  head.     Repeat  three  times, 

11.  Do  No.  9  with  heels  together. 
13.  Do  No.  10  with  heels  together. 

13.  Walk  along  a  fixed  line,  such  as  a  seam  on  the  carpet,  with 
cane,  placing  the  feet  carefully  on  the  line  each  time.  Walk  a 
distance  of  at  least  fifteen  feet.     Repeat  twice. 

14.  Do  the  same  without  cane. 

15.  Stand  erect  with  cane;  describe  a  circle  on  the  floor  with 
the  toe  of  the  right  foot;  same  with  the  left.  Repeat  twice.  Be- 
tween the  fifth  and  sixth  exercise  the  patient  should  rest  for  a  few 
moments. 

ELECTRICITY 

Physics. — The  laws  which  govern  the  electrical  current  are 
similar  to  those  governing  the  flow  of  water.  If  two  vessels  one 
above  the  other  and  connected  by  a  tubing,  and  water  is  poured 
into  the  higher  vessel,  it  will  tend  to  run  to  the  lower  vessel ;  the 
water  will  thus  generate  force  or  capacity  for  work  which  is  called 
polenfial.  The  fluid  in  the  lower  vessel  would  also  tend  to  reach 
a  low  level,  but  the  force  would  not  be  so  great  as  that  of  the 
higher  vessel;  at  sea-level  would  be  zero  potential.    The  difference 


ELECTEICITY  93 

in  force  exerted  between  these  two  bodies  of  water  would  be  their 
difference  in  potential. 

By  means  of  certain  agencies  (chemical  change,  friction)  elec- 
tricity is  separated  into  positive  and  negative  electricit}^,  the  posi- 
tive being  of  higher  potential  than  the  negative,  the  positive  tend- 
ing to  flow  towards  the  negative  and  thus  cause  an  electric  current. 
The  zero  point  of  an  electrical  current  is  the  earth. 

Volt. — The  force  which  starts  the  column  of  water  flowing  is 
gravity ;  that  force  which  causes  an  electric  current  to  flow  is  called 
electro-motor  force  (E.  M.  F.).  The  unit  of  measurement  of  this 
is  called  the  volt. 

Ohm. — Some  substances  are  much  more  pervious  to  the  passage 
of  water  than  others.  This  is  so  with  electricity.  Conductors  per- 
mit the  electric  current  to  flow  easily.  Metals,  plumbago,  dilute 
acids,  saline  solutions,  water,  and  living  animals  are  good  conduc- 
tors in  the  order  mentioned.  iVow-conductors  or  insulators  do  not 
permit  free  passage  of  electricity — such  as  rubber,  glass,  silk, 
resins,  and  dry  air. 

Just  as  water  encounters  resistance  as  it  flows  through  a  pipe, 
so  does  electricity  meet  resistance  as  it  passes  along  a  conductor; 
and  this  resistance  will  depend  upon  the  length,  composition,  and 
area  of  cross-section  of  the  conductor.  Thus  a  current  passing  a 
short  distance  through  a  good  conductor  of  large  area  of  cross- 
section  will  meet  with  less  resistance  than  a  current  when  passing 
through  a  poor  conductor  with  a  small  cross-section  area,  or  a  long 
distance.    The  unit  of  resistance  is  called  an  ohm. 

Ampere. — The  current  strength  (C)  is  dependent  upon  Ohm's 
law,  which  is  that  the  current  strength  is  equal  to  the  electro-motor 

-pi  -vr  Tji 

force    divided    by    the    resistance    (C  =     '!,'    ').      The    current 

strength  is  measured  in  amperes.  In  medicine  we  use  yoVo"  P^^^ 
of  an  ampere,  called  a  milliampere.  Wlien  electricit}^  is  confined, 
as  by  means  of  insulators,  it  is  said  to  be  static. 

Physiology. — Electricity  acts  in  various  ways  upon  living  tis- 
sues. It  possesses  the  power  of  cataphoresis — i.  e.,  it  may  carry 
solutions  through  the  tissues  in  the  direction  of  the  current.  By 
this  means  cocaine  for  anaesthesia  and  various  other  drugs,  as  mer- 
cury, may  be  carried  into  the  tissues.  Electricity  may  also  pos- 
sess the  power  of  electrolysis  or  chemical  decomposition  of  tissues 
at  the  electrodes.    By  this  destruction  of  n^vi,  or  small  tumours. 


94  TREATISE    ON    NERVOUS    DISEASES 

may  be  brought  about.  Electricity  also  causes  a  modification  of 
nerve-excitability  known  as  electrotonus.  In  the  vicinity  of  the 
anode  the  excitability  is  lessened — anelectrotonus ;  while  at  and 
in  the  vicinity  of  the  cathode  the  excitability  is  increased — cath- 
electrotonus.  When  anelectrotonus  is  made  to  suddenly  dis- 
apjDear  by  the  breaking  of  the  current  at  the  anode,  cathodal 
increase  occurs,  and  the  nerve  is  thrown  into  a  condition  of  cath- 
electrotonus. 

Electric  currents  also  cause  muscular  contraction,  and  this  is 
produced  by  a  sudden  increase  or  decrease  of  electrical  excitement 
in  the  muscle  or  the  nerve  supplying  it.  If  this  is  done  but  grad- 
ually no  contraction  results.  The  most  powerful  contraction  is 
therefore  caused  by  the  voltaic  alterative.  It  is  produced  by  sud- 
denly reversing  the  current  direction,  so  that  a  nerve  or  muscle 
that  was  in  a  condition  of  anelectrotonus  is  thrown  into  a  condi- 
tion of  cathelectrotonus,  or  from  a  state  of  —  excitability  to 
one  of  4"  positive,  and  vice  versa.  By  simple  closure  and  open- 
ing of  the  circuit  the  increase  is  only  from  0  to  -|-  excitability 
and  0  to  —  excitability,  which,  of  course,  is  not  so  great  a  vari- 
ation. 

The  galvanic  current  produces  all  of  these  properties  in  more 
marked  degree  than  does  the  faradic  or  static.  In  the  latter  two 
forms  the  influence  of  the  current,  due  to  constant  interruptions,  is 
so  brief  in  duration  that  they  are  practically  only  used  to  cause 
muscular  contraction  and  relieve  pain  respectively. 

A  degenerating  muscle  loses  its  power  of  response  to  static  elec- 
tricity first,  next  to  faradic,  then  to  simple  opening  and  closing 
of  the  galvanic  current,  and  finally  to  the  voltaic  alterative. 

Diagnosis  and  Prognosis. — In  many  diseases  of  the  nervous 
system,  particularl)^  cord  diseases,  the  muscles  and  nerves,  when 
submitted  to  electrical  stimulation,  act  differently  to  normal  mus- 
cles and  nerves.  This  electrical  irritability  may  differ  in  two  ways, 
quantitatively  and  qiialitatively. 

Change  in  quantity  implies  a  diminution  or  decrease  in  irrita- 
bility, while  change  in  quality  that  there  is  change  in  the  character 
of  the  contraction. 

Quantitative  Change. — Simple  increased  irritahility,  or  that  in 
which  the  muscle  or  nerve  responds  to  a  weaker  current  than  nor- 
mal, is  met  with  most  frequently  in  tetan3^  Decreased  irritahiliiy, 
or  that  in  which  a  stronger  current  than  normal  is  required  to  pro- 


ELECTEICITY  95 

duce  contractions,  occurs  in  mild  cases  of  neuritis,  and  occasion- 
ally in  long-standing  central  paralyses.  And  these  conditions  are 
generally  the  same  for  both  currents. 

Quantitative  Changes — Examination. — To  ascertain  these :  if 
the  paralysis  is  unilateral,  the  weakest  current  will  cause  con- 
traction on  the  normal  side  should  be  learned;  then  the  strength 
of  the  current  that  will  produce  the  same  result  on  the  diseased 
muscles  is  determined,  and  the  two  compared. 

If  the  disease  is  bilateral  the  reaction  may  be  compared  with 
the  reaction  of  a  normal  person  of  similar  physique,  or  judged  by 
experience  as  to  the  strength  of  current  usually  re(juired  in  the 
particular  muscles  tested. 

Qualitative  changes  consist  of  reaction  of  degeneration  (DeE,) 
and  of  the  myotonic  muscular  reaction,  the  former  being  found  in 
certain  peripheral  palsies,  and  therefore,  when  present,  always  in- 
dicates a  lesion  situated  in  the  peripheral  motor  neurone — i.  e., 
motor  cell  of  medulla  or  cord — or  in  the  axones  forming  the  motor 
nerves  that  come  from  this  motor  neurone;  while  the  latter  (myo- 
tonic muscular  reaction)  is  a  symptom  of  the  clinical  disease  myo- 
tonia congenita.     (See  Thomsen's  disease.) 

Reaction  of  degeneration  may  be,  according  to  the  degree  of 
disease  of  peripheral  motor  neurones,  partial  or  complete. 

Com.plete  reaction  consists  of  (a)  rapid  loss  of  the  power  of 
the  muscle  and  its  supplying  nerve  to  react  to  the  f aradic  current ; 
(&)  a  brief  period  of  quantitative  increase  followed  by  a  decrease 
when  they  are  stimulated  by  the  galvanic  current;  (c)  the  nodal 
change — i.  e.,  instead  of  the  short,  jerky  contraction  caused  by 
the  stimulation  of  the  healthy  muscle  or  nerve  by  the  galvanic 
current,  the  contraction  is  slow,  wavy,  and  at  times  tetanic;  and 
{d)  the  serial  change  when  the  muscle  alone  is  subjected  to  gal- 
vanic stimulation. 

The  partial  or  serial  change  depends  upon  a  difference  in  the 
way  the  muscle  reacts  to  different  poles  of  the  battery,  normally 
the  weakest  current  that  will  cause  a  muscular  contraction  is  when 
the  circuit  is  closed  .with  the  cathode  on  the  musfle  (cathodal 
closing  contraction  CaCLC)  ;  a  stronger  current  will  cause  an 
anodal  closing  contraction  (AnCLC),  etc.  If  we  represent  anodal 
opening  contraction  by  AnOC  and  cathodal  opening  by  CaOC,  the 
normal  formula  will  be 

CaClC>AnClC>AnOC>CaOO 


96  TEEATISE    OX    XERYOUS    DISEASES 

The  serial  change  in  complete  reaction  of  degeneration  (DeR) 
consists  of  an  increase  of  the  AnClC  and  AnOC  over  the  CaClC ; 
so  that  one  formnla  wonlcl  read  AnClC  =  AnOC  CaClC  CaOC,  or 
as  follows:  AnClO AnOC>CaClC>CaOC. 

Partial  DeE  is  more  usual  than  the  complete  as  just  given,  and 
may  consist  of  nothing  but  the  loss  of  faradic  irritability  and  the 
nodal  change,  the  series  remaining  normal.  The  series  may  be  so 
changed,  however,  that  AnClC  =  CaClC.  In  partial  reactions  the 
nerve  usually  responds  normally. 

Examination  for  the  Presence  of  DeR. — Here  we  first  use  the 
faradic  current  as  when  testing  for  quantitative  changes.  Then 
use  the  large  galvanic  electrode  over  the  sternum,  and  the  other, 
a  small  one,  over  the  muscle.  This  will  show  the  minimum 
strength  of  current  necessary  to  cause  CaClC  and  AnClC.  If 
a  milliamperemeter  is  attached,  we  can  note  the  number  of 
milliamperes  required ;  or  if  not,  by  noting  that  the  current  which 
causes  CaClC  will  not  cause  AnClC,  or  vice  versa,  or  that  they 
are  equal. 

Anotlier  method  consists  in  making  the  electrode  positive 
or  negative  alternately,  using  the  same  strength  of  current 
and  noting  the  difference,  if  any,  in  the  degree  and  intensity 
of  contractions.  In  all  of  these  tests  there  should  be  an  interval 
of  several  seconds  permitted  between  opening  and  closing  the 
circuit. 

The  myotonic  reaction  is  due  to  a  much  increased  irritability; 
mild  faradic  and  galvanic  currents  produce  contractions  that  are 
tetanic  in  character,  hollows  and  ridges  in  the  muscle  being  fre- 
quently produced.  In  the  case  of  the  galvanic  current  AnClC 
becomes  equal  to  or  greater  than  CaClC.  When  the  galvanic  cur- 
rent is  allowed  to  pass  without  interruption  through  a  muscle, 
rhythmical  contractions,  travelling  from  negative  to  positive  pole 
occur. 

Electricity  may  at  times  help  in  giving  a  prognosis — e.  g., 
complete  DeR  is  only  present  when  extensive  damage  has  been 
done;  the  prognosis  is  more  grave  than  when  the  reaction  only 
shows  partial  DeR,  particularly  when  in  the  clinical  signs  the 
anterior  horns  of  the  cord  show  involvement.  Per  contra  it  is 
better  in  nerve-trunk  lesion  per  se.  Prognosis  is  best  in  cases  where 
no  serial  changes  occur.  In  cases  where  only  feeble  AnClC  can 
be  elicited,  it  is  usually  hopeless. 


ELECTEICITY  97 


GENERATION    OF    ELECTRICITY    FOR    PRACTICAL 

THERAPY 

Electricity  is  generated  in  a  cell  composed  of  two  opposing 
elements,  one  being  called  positive,  the  other  negative,  both  of 
these  being  placed  in  the  same  solution,  a  good  conducting  medium, 
as,  for  example,  sulphuric  acid.  Then  the  current  is  given  o£E 
from  the  battery  at  the  softer  metal— for  instance,  the  zinc.  A 
current  thus  set  up  passes  from  the  negative  to  the  positive  pole 
within  the  "  cell,"  so  called,  thence  out  a  conducting  wire  to  tlie 
electrode  or  pole,  designated  the  positive  pole,  and  from  which  the 
current  passes  when  applied  to  the  human  body.  The  pole  or 
electrode  from  which  the  current  passes  to  the  other  conducting 
wire  back  to  the  "  cell "  is  called  the  negative  or  active  pole  of  the 
battery.  This  apparatus,  simply  described,  is  designated  a  galvanic 
or  chemical  instrument,  and  is  most  potent  for  action  upon  the 
tissues.  A  practical  method  of  determining  which  pole  is  negative 
or  not  is  perhaps  best  made  by  placing  the  electrodes  in  water ;  the 
one  from  which  bubbles  escape  is  the  negative,  active,  or  electro- 
lytic pole.  A  good  point  also  for  remembering  which  pole  is  the 
more  active  is  to  be  guided  by  the  paradoxical  fact  that  the  "  nega- 
tive pole  "  is  the  positive  one  for  action,  while  the  "  positive  pole  " 
is  the  negative  one  in  regard  to  its  effect  upon  human  tissues.  Gal- 
vanic electricity  produces  profound  action  upon  the  human  body, 
and  is  the  one  used  where  there  are  the  so-called  degenerations, 
if  electricity  has  been  prescribed  for  the  case. 

SOME    PRACTICAL    INDICATIONS    FOR    GALVANISM 

In  treating  a  case  of  Bell's  palsy  do  not  begin  the  application 
earlier  than  from  ten  days  to  two  weeks  following  the  attack.  Ap- 
ply the  positive  pole  to  the  nape  of  the  neck,  the  negative  being 
applied  to  the  distribution  of  the  peripheral  nerve  upon  the  face, 
.from  3  to  6  millimetres  being  used.  So  with  other  local  palsies 
where  "  reaction  of  degeneration "  has  been  found,  such  as  in 
wasting  of  muscles  from  infantile  palsy,  or  in  brachial  and  sciatic 
neurites. 

In  the  tachycardia  of  Graves's  disease,  the  application  of  from 
4  to  6  millimetres  of  current  for  as  many  minutes  will  often  act 
favourably  in  slowing  cardiac  action,  through  stimulation  of  the 


98  TEEATISE    ON    XEETOUS    DISEASES 

vagi.    Place  the  negative  pole  over  the  apex  and  the  positive  over 
the  carotids  by  an  extension  of  the  positive  pole  in  Y-shape. 

The  removal  of  superfluous  hair  can  be  accomplished  through 
a  galvanic  current,  as  follows;  by  cathode  application  to  the  root 
of  the  hair  within  its  follicle :  For  this  purpose,  a  very  fine  flexible 
steel  needle  securely  fastened  in  a  plain  insulated  holder  is  passed 
down  along  the  hair  to  be  removed  from  its  follicle.  There  should 
be  neither  resistance  nor  pain;  if  there  be,  the  edge  of  the  follicle 
has  been  struck  and  the  attempt  to  introduce  the  needle  must  be 
repeated.  The  oifending  hair  is  held  by  means  of  a  small  forceps, 
by  which  it  is  extracted  later. 

The  circuit  is  completed  by  the  patient  placing  her  hand  upon 
the  wetted  sponge  anode.  The  current  must  be  imperceptible,  and 
within  twenty  or  thirty  seconds  of  its  passage  froth  appears  about 
the  needle,  and  a  short  while  thereafter  the  hair  pops  out  without 
traction  on  the  forceps.  The  patient  then  removes  the  hand  from 
the  sponge,  and  another  hair  is  selected  for  the  same  treatment. 
This  subject  is  mentioned  in  detail  since  it  is  a  valuable  means 
of  helping  us  in  the  therapeutics  of  melancholia  in  sensitive  women 
due  to  excessive  hirsute  gTOwth.  I  have  seen  excellent  results  in 
the  mental  disorder  where  other  therapeusis  had  failed. 

The  galvanic  is  also  the  current  used  for  the  relief  of  pain,  as  in 
neuralgia;  and  the  positive  pole  should  be  applied  to  the  painful 
part  in  such  cases,  the  negative  pole  to  be  applied  to  some  indif- 
ferent distant  part  of  the  bod}^  It  should  not  be  administered 
longer  than  five  minutes  at  one  seance.  When  the  current  is  pass- 
ing and  both  poles  are  applied,  it  is  termed  "  closed,"  and  when 
one  pole  is  removed  or  the  circuit  broken  by  the  spring  attachment 
placed  on  the  negative  electrode,  it  is  termed  "  open."  There  are 
certain  definite  relations  in  reaction  of  the  muscles  to  the  current. 
First,  when  the  current  is  closed,  the  negative  pole,  being  placed- 
over  the  biceps  muscle — for  example,  the  positive  over  the  dorsal 
spine — there  is  contraction  well  seen  at  the  moment  of  closing. 
When  we  reverse  the  pole,  the  positive  being  placed  over  the  biceps 
muscle  and  the  negative  over  the  spine,  you  will  see  that  at  closing 
of  the  current  by  the  attached  spring  or  interrupter  the  contrac- 
tion of  the  normal  muscle  is  much  less  marked  at  closing. 

"  Eeaction  of  degeneration "  is  always  made  with  a  galvanic 
current;  never  determined  in  palsies  the  results  of  the  cerebral 
disease — i.  e.,  of  central  origin — but  is  found  in  lesions  of  the 


ELECTRICITY  99 

peripheral  neurone,  as  in  disease  of  the  anterior  horns  of  gray 
matter  of  the  cord,  neuritis  or  other  degenerative  diseases  of  nerv- 
ous tissues,  peripheral  to  and  including  the  multipolar  cells  of  the 
gray  matter  of  cord  or  medulla,  as  indicated  above. 

The  order  of  lessening  the  contraction  of  muscles  with  begin- 
ning degeneration  of  nerves,  finally  represented  in  "reaction  of 
degeneration,"  is  as  follows : 

CaClOAClC 

AC1C<CC1C 
ACIOCCIC  >     AOC. 

The  formula  AOC>CaOC  always  obtains,  however. 

Ruddiness  appears  at  the  point  of  contact  of  the  negative  pole 
upon  the  skin,  as  over  the  biceps  muscle,  and  if  the  current  is  made 
strong  enough  or  allowed  to  pass  a  few  moments,  a  peculiar  "  ting- 
ling "  sensation  will  arise,  and  finally  an  actual  "  burning," 
which,  indeed,  can  go  on  to  excoriation  where  the  current  is  al- 
lowed to  pass  of  too  great  strength.  You  will  find  for  use  in  the 
upper  extremities  an  average  of  5  to  10  milliamperes  is  quite 
enough,  as  shown  by  the  attached  milliamperes  through  its  needle 
index. 

REGULATIONS  OF  THE  GALVANIC  CURRENT 

The  rheostat  governs  the  amount  of  electricity  passing  from 
the  battery  to  the  body.  A  convenient  movable  lever  with  IST.  upon 
the  index,  when  pushed  far  to  the  right  or  left,  always  points  to 
the  negative  pole,  and  in  larger  machines  the  current  is  obtained 
from  a  series  of  galvanic  "  cells."  Therefore  we  can  take  the  cur- 
rent in  different  wards  of  a  hospital  by  a  transfer  cabinet,  or  "  con- 
verter." For  use  in  private  work,  we  generally  •  carry  a  galvanic 
battery  of  20  to  30  cells.     (See  illustration.) 

AXIOMS 

A  few  axioms  and  terms  used  in  electro-therapeutics  it  will 
be  well  to  define.  The  force  originating  in  a  current  is  designated 
as  the  electro-motor  force.  The  strength  of  current  used  upon  the 
body  is  equal  to  the  electro-motor  force  plus  internal  and  external 
resistance.  Ohm's  law  is  that  the  strength  of  the  current  is  equal 
to  the  electro-motor  force  divided  by  the  external  and  internal  re- 
sistance. Stabile  application  of  a  continuous  current  is  where  the 
7 


100 


TEEATISE    OX    XEEYOUS    DISEASES 


poles  are  first  applied  in  one  place,  then  the  current  turned  grad- 
ually on.  Labile  is  where  the  galvanic  or  interrupted  currents  are 
set  up  first,  then  the  poles  placed  to  the  parts  to  be  treated  and 
constantly  mo-\'ed  from  one  nodal  ^  point  to  another. 


Fig.   21. — Complete  Gjllyassig  Dry-Cell  Battery  (with  milliamperemeter  and 

rheostat). 

The  current  that  produces  the  greatest  contraction  of  the  mus- 
cles with  the  least  pain  is  always  applied. 

A  "  dry "  cell  is  one  in  which  the  conducting  medium  in  the 
hatterT  is  not  a  liquid,  and,  while  convenient,  is  not  to  he  depended^ 
upon  as  is  the  "wet"  ceU. 

The  sinusoidal  current  is  one  that  comes  in  therapeutics  be- 
tween the  galvanic  and  faradic  currents.  It  is  a  current  of  greater 
intensity  and  less  in  quantity  than  the  galvanic  current,  and  is 
the  result  of  insertion  of  a  series  of  magnets  in  the  galvanic  cur- 
rent. It  is  used  as  a  stimulating  agent  in  cases  of  extreme  atrophy 
of  muscles,  etc. 


'  Nodal  points  are  points  of  constant  potential  in  a  muscle, 
more  imtable  than  others. 


Motor  points  are  points  in  a  muscle 


ELECTEICITY 


101 


FARADIC    ELECTRICITY 

The  faradic  current  is  the  so-called  induced  or  interrupted  cur- 
rent, and  is  generated  from  a  cell  in  a  like  manner  to  the  galvanic 
current  as  described.  It  is,  however,  so  modified  by  the  interposi- 
tion -of  a  coil  of  fine  iron  wires  as  to  change  the  character  of  the 
electricity  by  "induction"  to  great  electro-motor  force;  but  it  has 
little  chemical  power  compared  to  that  of  the  continuous  or.  gal- 
vanic current,  because  the  fact  of  breaking  a  current  with  the  in- 
ductive coil  changes  the  manner  entirely  in  its  action  upon  the 
human  body.  This  current  is  simply  used  for  the  exercise  or  devel- 
opment of  muscular  tissue  because  it  produces  contraction  of  mus- 
cle.    These  contractions  are  either  rapids,  when  the  rapid  inter- 


FiG.  22. — Combination  Dry-Cell  Galvanic  and  Faradic  Battery. 


rupter  is  used,  or  sloiv^  as  when  the  large  lever  is  placed  within 
the  current  and  by  magnetization  is  caused  to  swing  to  and  fro 
slowly. 

In  using  this  kind  of  electricity  pain  is  not  produced  in  the 
patient  so  easily  as  it  can  be  produced  by  the  galvanic  current;  at 
least,  not  of  that  burning  or  chemical  character,  as  has  been  men- 
tioned. In  fact,  we  do  not  think  of  using  the  word  qualitative 
in  relation  to  faradic  electricity,  since  quantity  of  contraction  and 
but  little  or  no  qualitative  symbolism  maintains;  so  little,  indeed, 


102 


TREATISE    OK   NERVOUS    DISEASES 


that  it  is  not  necessary  to  tax  the  memory  with  the  very  small 
amount  of  difference  between  contractions  made  when  the  positive 
faradic  pole  or  the  negative  is  placed  over  the  muscle  stimulated; 
since,  too,  the  pole  is  changed  through  the  fact  that  the  direction  of 


FiQ.  23. — Complete  Electric  Cabinet  (with  dj'namo  alternator). 

the  current  is  changed  with  each  interruption  caused  by  the  act 
of  induction  itself. 


USES    OF    FARADIC    ELECTRICITY 

The  faradic  current  is  used,  as  has  been  inferred,  for  the  de- 
velopment of  the  muscles.  The  "  rest  treatment,"  consisting  of 
massage,  isolation  and  rest  in  bed,  full  feeding  and  electricity,  is 


ELECTEICITY  103 

aided  by  faradism  very  much  in  the  efficiency  of  the  fullest  treat- 
ment and  benefit  to  the  large  majority  of  cases.  The  application 
of  faradism  to  the  human  body,  as  typified  in  this  course  of  treat- 
ment, we  shall  now  indicate.  This  consists  of  about  forty-five 
minutes'  application  in  the  following  fashion :  The  patient  should 
be  in  repose  and  treated  at  about  midway  between  the  meals,  prefer- 
ably in  the  morning  or  afternoon  or  early  evening,  all  depending 
upon  the  time  of  giving  massage,  the  two  separated  widely  in  the 
waking  hours.  The  room  should  be  at  about  75°  F.  in  the  ma- 
jority of  instances  of  neurasthenia,  or  varying  with  the  idiosyn- 
crasy of  the  case ;  the  point  being,  of  course,  to  prevent  "  catching 
cold."  Having  the  patient  placed  on  one  side  and  thoroughly  re- 
laxed, the  rapid  current  is  applied  to  the  feet  by  metallic  electrodes 
well  covered  with  absorbent  cotton.  This  will  not  take  more  than 
five  minutes,  and  will  produce  an  agreeable  sensation  of  tingling 
to  the  patient,  warming  the  extremities  at  the  same  time.  Then 
the  slow  interrupter  is  placed,  and  the  two  poles  are  applied  over 
the  bellies  of  the  extensor  and  flexor  muscles  of  the  leg  alternately, 
producing  in  each  separate  group  well-marked  contractions  at  the 
breakings  of  the  current.  This  will  take  five  minutes  more.  The 
thigh  is  treated  in  the  same  wa}^,  producing  again  as  strong  con- 
tractions of  the  muscle  as  possible  without  causing  pain,  the  guid- 
ing principle  being  never  to  produce  pain  in  administering  any 
form  of  electricity.  The  other  limb  is  treated  in  the  same  manner, 
the  patient  being  turned  on  the  opposite  side  and  the  treated  limb 
being  wrapped  in  a  blanket  for  protection.  This  will  have  con- 
sumed about  twenty-five  minutes.  The  upper  extremities  are 
treated  in  like  manner,  and  you  will  find  the  current  much  more 
easily  perceived  here  by  the  patient.  The  agreeable  sensation  given 
to  the  hand  by  the  rapid  current  is  most  soothing,  while  the  con- 
tractions induced  in  the  forearm  muscles,  then  in  the  arm  and 
shoulder  girdle  musculature  will  have  caused  a  sense  of  warmth 
and  stimulation  to  the  whole  of  the  members.  Now  apply  the  cur- 
rent for  about  twenty  minutes  upon  the  upper  members — a  shorter 
time  than  applied  to  the  lower  limbs,  but  quite  as  efficient,  however, 
since  the  upper  extremities  and  their  muscles  are  much  more  easily 
manipulated.  The  blanket  being  folded  across  the  chest  protects 
this  part  of  the  anatomy,  and  while  a  cover  also  remains  across 
the  lower  limbs  (the  patient  lying  supine),  the  broad  flat  muscles 
of  the  abdominal  walls  are  next  treated.     Then  the  patient  can  be 


104  TEEATISE    ON    XEEYOUS    DISEASES 

turned  over  on  the  abdomen,  the  erector  spinge  group  of  muscles 
are  given  a  few  moments'  contraction  pr  exercise,  when  the  case 
will  have  been  fully  treated.  The  patient  is  now  well  covered,  with 
the  blanket  kept  next  to  the  skin,  and  perfect  quiet  being  insisted 
upon,  he  is  apt  to  fall  ofE  into  a  delicious  slumber. 


Pig.  24. — Static  Machine  and  Complete  Series  of  Electrodes. 

Thus  the  patient  gets  objective  exercise  without  calling  upon 
his  subjective  state — i.  e.,  the  central  nervous  system — to  furnish 
force  from  his  own  vitality,  which  is  needing  the  rest.  It  must 
be  remembered  we  are  describing  the  typical  case,  and  as  with  mas- 
sage, exceptional  instances  occur  which  for  some  reason  in  an 
hysterical  or  excitable  neurasthenic  electricity  will  not  be  well 
borne.  It  should  be  stated  also  that  the  felicity  and  facility  with 
which  the  faradic  current  is  applied  depend  upon  the  amount  of 


HYPXOTISM  105 

practice  and  experience  gained  from  persistent  effort  to  do  the 
thing  well.  With  this  ease  of  execution  you  will  find  the  time  of 
application  can  be  cut  down  very  much,  and  with  the  same  efficacy 
to  the  patient. 

The  faradic  brush  attached  to  the  negative  pole  to  produce  irri- 
tation is  another  tonic  method  of  applying  the  induced  current, 
useful  in  such  symptoms  as  hysterical  anesthesia.  The  skin  should 
be  dry  when  this  is  employed. 

FRANKLIN    OR    STATIC    ELECTRICITY 

This  electricity  is  generated  through  friction,  as  of  a  revolving 
wheel  upon  leather  or  wool.  It  is  a  current  of  very  low  electro- 
motor force,  but  with  great  intensit}',  and  is  used  simply  as  a 
stimulant  to  arouse  better  circulation,  such  as  in  chronic  rheuma- 
tism, old  cases  of  hemiplegia,  lumbago,  and  in  chronic  articular 
disease  with  joint  pains.  It  is  also  a  most  active  tonic,  and  a 
spark  passed  up  and  down  the  spinal  column — the  patient  being 
placed  on  the  insulating  stool  for  three  to  five  minutes — serves 
mightily  to  awaken  nerve  energy  in  one  who  is  neurasthenic  or 
in  ephemeral  nerve-tire  from  whatever  cause. 

Before  giving  this  current  especially  should  the  patient  be 
warned  else  he  might  interpret  the  snap  of  the  spark  as  something 
serious,  whereas  it  is  so  rapid  and  of  such  a  minimum  c[uantity 
that  there  is  no  danger  whatever,  and,  indeed,  burning  of  the 
clothing  or  even  of  a  piece  of  paper  placed  between  the  poles  will 
never  occur.  You  regulate  the  amount  of  current  to  the  pleasant 
sensation  produced  in  the  patient.  This  is  done  by  sliding  resist- 
ance rods  more  closely  together,  thereby  lessening  the  resistance 
which  the  body  itself  T\-ould  otherwise  have  to  perform,  and,  of 
course,  with  greater  discomfiture.  The  static  breeze  is  a  milder 
form  and  can  be  used  upon  the  scalp  for  neurasthenic,  helmet-like 
headache.     (See  Fig.  24.) 

HYPNOTISM 

By  hypnotism  (from  Gr.  liypnos — sleep)  we  refer  to  the  induced 
sleep  or  state  of  sleep  produced  in  a  subject  by  a  second  person.^ 
It  is  more  easily  induced  in  persons  or  individuals  the  subject  of 

1  Some  authors  claim  that  there  is  a  self-induced  hypnotism,  but  this  will 
be  found  to  be  the  result  of  suggestion  immediate  or  remote  from  a  second 
person  in  every  instance. 


106      .       TREATISE    OX    XEEVOUS    DISEASES 

highly  nervous  temperaments,  or  actually  suffering  from  some  func- 
tional nervous  disease.  Some  psychologists  contend  that  hypno- 
tism can  be  induced  in  the  best  minds  as  readily  as  in  those  persons 
referred  to,  but  this  is  not  my  experience,  although  I  have  seen 
a  very  intelligent  man  hypnotized  after  a  prolonged  effort.  In 
medicine,  hypnotism  should  be  used  entirely  as  a  curative  agent. 
The  school  of  Berhheim  and  Charcot  have  developed  this  form  of 
therapeutics  more  than  any  other;  and  while  there  are  a  number 
of  different  stages  given  by  certain  authorities  on  this  subject,  it  is 
sufficient  to  here  define  only  three  stages  of  the  hypnotic  state: 
(1)  That  of  lethargy,  in  which  the  patient's  mind  is  obtunded. 
He  breathes  easily  and  the  circulation  is  quiet.  In  a  few  moments 
in  the  typical  instance  of  hypnosis  the  patient  will  pass  into  (2) 
catalepsy,  which  latter  consists  of  the  lethargic  state  plus  muscle 
rigidity,  and  from  this  the  subject  gradually  passes  into  (3)  som- 
nolence, when  he  breathes  deeply  and  is  apparently  sleeping  in  a 
relaxed  state.  These  three  subdivisions  are  not  accurately  defined 
in  the  majority  of  subjects,  one  predominating  over  the  other, 
depending  upon  the  idiosyncrasy  of  the  case.  The  methods  of 
inducing  hypnotism  are  many,  but  all  depend  upon  the  same  phe- 
nomena— namely,  absorbing  the  patient's  interest  entirely  in  one 
direction,  having  prepared  him  by  the  suggestion  that  he  should 
think  of  nothing  but  sleep  and  at  same  time  try  to  sleep.  The 
holding  of  revolving  mirrors  before  the  eyes  or  any  bright  object 
for  fixation  will  be  the  instrumentality  used.  The  physician,  of 
course,  must  have  the  bearing  of  confidence  to  impress  the  patient, 
and  the  subject  should  be  told  that  nothing  will  be  done  save  the 
desire  to  cure  the  given  ailment.  It  is  well  to  have  the  person 
in  a  Cjuiet  room  and  to  fix  the  eyes  in  a  strained  position  so  that 
they  soon  tire.  Thus  the  conscious  mind  is  held  in  abeyance  and 
the  subconscious  mind  alone  predominates,  the  subject  passing 
under  the  control  of  the  manipulator.  It  is  desirable  to  place  the 
patient  in  the  third  stage,  if  possible,  before  attempting  sugges- 
tion, although  in  difficult  subjects  suggestions  for  cure  may  be  of 
avail  even  when  the  patient  does  not  pass  beyond  the  lethargic 
stage.  The  suggestion  for  cure  should  be  made  while  the  patient 
is  hypnotized,  and  for  practical  success  should  not  be  too  dogmat- 
ic, as,  for  example,  in  case  of  hysterical  palsy.  In  this  way  the 
doctor  has  better  control  and  the  patient  is  not  disappointed; 
moreover,  the  physician  will  more  likely  be  able  to  succeed  in  the 


THE    EEST    TREATMENT  107 

hyi^notism  of  the  subject  at  another  time  if  he  fails  in  the  first  at- 
tempt. Indeed,  in  many  patients  or  subjects  tliat  are  really  suscep- 
tible to  hypnotism,  it  will  be  found  that  it  must  be  resorted  to  at 
different  times  before  suggestion  for  cure  can  be  pressed  upon 
them.  The  post-liypnotic  suggestion,  so  called,  which  consists  in 
the  endeavour  to  induce  in  the  subject  hypnotized  the  doing  of 
certain  acts  or  the  producing  in  them  of  certain  sensations  long 
after  the  hypnotic  state — thus,  a  suggestion  that  tobacco  will  be 
unpleasant  to  the  tobacco  fiend — is  a  possibility. 

Hypnotism  has  a  very  limited  range  and  should  be  used  as 
a  last  resort  in  cases  where  the  ordinary  mental  influence  of  the 
physician  does  not  avail.  It  is  especially  of  value  in  local  hyster- 
ical palsies,  either  sensory  or  motor,  and  is  distinctly  of  less  value 
as  the  functional  paralysis  is  more  general.  Cases  of  hysterical 
hemi-an^esthesia  I  have  never  seen  benefited  by  its  use. 

THE    REST    TREATMENT 

This  method  of  treatment,  devised  by  S.  Weir  Mitchell,  is  of 
especial  value  in  neurasthenia  and  hysteria. 

Its  essential  features  are  isolation,  absolute  rest,  diet,  massage, 
electricity,  and  the  personal  influence  of  a  good  nurse. 

Isolation  from  the  patient's  family  and  former  surroundings 
is  essential.  The  diet^,  if  the  digestion  is  bad,  should  be  entirely 
of  milk.    Otherwise  easily  digested  solid  food  may  alternate  with  it. 

Rest  must  be  absolute  in  severe  cases;  even  sitting  up  in  bed 
should  not  be  allowed.  The  duration  of  the  treatment  should  be 
from  four  to  eight  weeks. 

The  following  schedule,  as  given  by  Dr.  J.  K.  Mitchell,  will 
illustrate  the  method : 

7  A.  M. :  Cocoa ;  cool  sponge-bath,  with  rough  rub  and  toilet 
for  the  day. 

8  A.  M. :  Milk.     Breakfast.     Eest  for  one  hour. 
10  A.  M. :  Eight  ounces  peptonized  milk. 

■  11  A.  M. :  Massage.     (See  previous  section.) 
12  N. :  Milk  or  soup.    Eeading  aloud  by  the  nurse. 
1.30  p.  M. :  Dinner.    Rest  one  hour. 
3.30  p.  M. :  Eight  ounces  peptonized  milk. 
4  P.M.:  Electricity  (general  faradization). 
6  p,  M, :  Supper,  with  milk. 


108  TKEATISE    ON    NERVOUS    DISEASES 

8  p.  M. :  Eeading  aloud  b}^  nurse  for  one-half  hour. 

9  p.  M. :  Light  rubbing  by  nurse  with  drip-sheet. 

Eight  ounces  malt  extract  with  meals ;  tonic  after  meals.  Eight 
ounces  peptonized  milk  with  biscuit  at  bedtime,  and  a  glass  of 
milk  during  the  night,  if  desired. 

This  may  be  modified  in  various  ways  according  to  the  symp- 
toms. If  a  mild  case,  the  patient  may  be-allowed  to  sit  up  for  a 
few  hours,  or  even  go  out  for  a  drive. 

Object  of  the  "  Rest  Treatment." — Of  which  rest  is  the  essen- 
tial factor,  is  (1)  to  secure  repose  and  time  for  recuperation  from 
exhausted  nervous  states,  and  this  is  assisted  by  ( 2 )  isolation  from 
friends  and  other  sources  of  cause  for  expenditure  of  nerve-energy; 
then  comes  (3)  massage  and  electricity,  both  agents  to  mechan- 
ically exercise  the  muscles,  to  hurry  the  blood  and  lymph  streams 
on,  and  to  stimulate  metabolism  without  using  up  the  patient's 
little  reserve  force.  To  use  Dr.  S.  Weir  Mitchell's  apt  phrase, 
"  massage  and  electricity  deprive  rest  of  its  attendant  evils."  Im- 
agine any  one  in  health  lying  abed  for  twelve  weeks  or  more  with- 
out this  excellent  energizing  agent.  He  would  more  likely  waste 
than  gain  in  nerve  or  muscle  tone,  and  even  if  his  weight  should 
possibly  increase  during  the  time,  it  would  be  in  flabby  tissues, 
the  majority  of  which  would  be  only  deceptive  evanescent  fat.  Fat 
in  itself  is  a  burden,  not  a  gain,  to  the  individual.  Better  be 
"  lean  "  and  hardened,  as  the  athlete  or  thoroughbred,  than  to  have 
excess  of  the  so-called  panniculvs  adiposus. 

ON    THE    CARE    AND    TREATMENT    IN    CONVALES- 
CENCE   FROM    FUNCTIONAL  NERVOUS   DISEASE 

There  is  no  department  of  neurology  more  neglected  than  the 
proper  understanding,  or  at  least  if  appreciated  the  neglect  of 
sufficient  advice  to  convalescents  from  serious  disorder  of  the 
nervous  system;  and  in  this  place  we  shall  devote  especial  con- 
sideration to  functional  diseases,  those  so  considered  in  the  ab- 
sence of  accurate  scientific  data  to  throw  the  light  of  a  definite 
pathology  upon  many  cases  of  them.  Therefore  those  diseases 
to  be  discussed  shall  be"  naturally  enough  neurasthenia,  hys- 
teria, and  chorea — the  author  admitting,  however,  that  there  are 
many  cases  secondary  to  some  physiologic  perversion  or  to  an  irri- 
tation ;  still,  as  it  is  always  difficult  to  determine  the  fo7is  et  origo 


TEEATMENT    IN    CONVALESCENCE  109 

malij  the  majority  of  cases  are  usually  set  down  in  the  text-books 
as  functional.  As  it  is  not  intended  to  be  specially  scientific  as  to 
aetiology,  and  as  the  resultant  disease  (whether  functional  or  due 
to  primal  causes  other  than  the  ordinary  overwork,  mental  strain^ 
etc.)  is  the  same,  the  treatment  of  convalescents  from  either  essen- 
tial or  from  secondary  neurasthenia  would  be  in  large  measure 
alike.  Dismissing  at  once  this  subject  of  getiology — not  because 
of  its  lack  of  importance,  for  we  purpose  insisting  upon  the  keep- 
ing clear  of  all  causes  for  the  development  of  a  secondary  condition 
in  the  beginning  or  at  any  stage — we  shall  formulate  certain  prin- 
ciples to  be  obeyed  in  the  management  of  cases  where  diagnosis 
of  the  diseases  under  discussion  has  been  established;  in  other 
words,  the  care  of  the  patient  after  the  malady  has  fully  developed 
and  has  been  treated  successfully  towards  the  happy  issue  of  cure, 
which  latter  can  be  maintained  only  by  the  principles  that  we  shall 
attempt  to  lay  down  in  this  contribution.  "We  will  include  there- 
fore, in  this  practical  treatise,  suggestions  for  the  betterment  of 
the  person  who  is  called  by  the  physician — for  the  want  of  a  better 
name — "  generally  nervous,"  the  result  of  previous  functional 
nervous  disease. 

Mental  Care. — In  the  first  place,  these  patients  must  be  schooled 
or  educated  in  self-control.  This  may  seem  to  savour  a  bit  of 
charlatanism;  but  when  the  profession  learn  to  better  appreciate 
that  there  is  really  a  psychologic  basis,  a  suggestion,  in  this  form 
of  therapeusis,  there  will  be  less  chance  for  Christian  Science  and 
other  fads,  with  more  adherence  to  true  medicine,  so  that  the 
proper  balance  may  some  day  be  reached,  and  the  modest  medium 
of  common  sense  more  generally  prevail.  Nor  will  there  exist, 
at  that  happy  time,  any  basis  for  the  rather  trite  slur  at  the  social 
fabric  which  "  Mr.  Dooley  "  has  recently-  expressed,  in  effect,  that 
Christian  Science  believes  there  is  no  disease,  and  physicians  be- 
lieve that  everything  is  disease. 

A  certain  amount  of  time  will  be  required  therefore,  by 
the  alienist  and  neurologist,  in  explaining  away,  to  intelligent 
people,  certain  fads  with  which  they  have  become  infected;  and 
while  the  task  is  a  hard  one,  results  of  treatment  will  show 
a  fair  enough  proportion  of  success,  and  the  doctor  will  at 
least  be  given  credit  for  making  the  endeavour  to  rid  society  of 
these  baneful  influences.  Of  course,  if  you  are  dealing  with  a 
crank,  diplomacy  will  be  shown  by  dropping  the  subject.     As  it 


110  TEEATISE    OX    XERVOUS    DISEASES 

has  well  been  expressed  by  some  one,  "  You  can  take  a  crank  by  the 
hand,  but  cannot  lead  him  on."  With  these  few  words,  we  shall 
dismiss  the  somewhat  mysterious  side  of  medicine,  so  essential  to 
success,  however,  and  pass  to  more  scientific  truths — the  care  of  the 
human  body  physically,  the  better  understood  and  more  easily  ex- 
plained matter. 

Physical  Care. — Most  patients,  after  an  attack  of  acute  or  pro- 
longed functional  disease,  feeling  the  burden  lessened  and  cure  set 
in,  will,  in  their  exhilaration,  and  from  the  fact  that  the  nervous 
system  does  not  feel  the  insult  at  first,  go  back  to  the  usual  method 
of  life — of  strain  and  overwork — ^with  a  zeal  that  will  usually  pre- 
cipitate disaster  if  persisted  in;  so  that,  as  regards  rest,  the  con- 
valescent vshould  be  taught  responsibility  in  the  care  of  himself. 
If  he  refuse  to  carry  out  our  directions,  the  result  cannot'  be 
blamed  upon  his  physician.  These  are  they  who  pass  from  one 
reputable  man  to  another,  without  any  permanent  good  results. 
This  is  only  within  the  bounds  of  reason,  and  does  not  necessarily 
require  scientific  demonstration,  valuable  as  that  may  be.  It  is 
an  axiom  of  nature  that  rest  should  follow  after  the  central  neu- 
rones have  once  been  depleted,  ph5^siologically  or  pathologically. 
Even  in  cases  of  hysteria  with  full  muscular  vigour,  I  doubt  if 
overuse  of  the  muscular  system  wiU  but  prevent  fullest  recovery. 
In  the  cases  of  hysterical  palsies,  it  is  necessar}^  however,  to  en- 
courage exercise  to  a  limited  degree  in  order  to  give  confidence 
to  the  patient,  as  well  as  for  development  of  the  wasted  muscles. 
Thus,  the  most  desirable  forms  of  exercise  during  the  late,  ultimate 
convalescence  from  neural  maladies  are  in  a  general  way  to  be 
made  different  from  the  exercise  obtained  by  the  patient  in  his 
usual  routine  of  life ;  and  here  again  the  psychologic  element  must 
enter  prominently  as  the  reason  for  this  betterment.  Exercises, 
therefore,  that  keep  the  patient  away  from  his  usual  line  of 
thought,  or  prevent  him  from  thinking  about  self,  are  to  be  en- 
joined. And  if  the  patient  can  be  kept  off  his  limbs,  it  will  be 
more  advantageous  for  rest  of  the  central  nervous  s^'stem,  and 
thus  recreate  that  reserve  force  which  has  become  wanting  in  them. 
vSo  that  rowing,  canoeing,  horseback-riding  will  be  much  more  valu- 
able than  golfing,  tennis-playing,  or  bowling. 

Adjuncts  and  Medication. — It  is  important  to  treat  symptomat- 
ically  organs  that  are  disturbed  in  function  during  convalescence 
from  the  diseases  under  discussion ;  thus,  in  cases  of  gastralgia  or 


TEEATMEi^T    m   CONVALESCENCE  111 

of  supersensitiveness  of  the  gastrointestinal  tract,  it  may  be  neces- 
sary to  treat  the  mncous  membrane.  •  In  these  cases,  we  have  a 
neurosis  of  the  vagi  nerves  and  of  the  abdominal  sympathetic 
system. 

In  the  case  of  Mrs.  W.,  a  woman  of  delicate  constitution,  aged 
thirty-six,  under  the  writer's  care,  suffering  from  essential  neuras- 
thenia, the  result  of  society  indulgence,  one  of  the  most  annoying 
features  in  convalescence  was  subjective  sensation  of  distress  in  -the 
abdomen.  Three  years  previously,  this  had  assumed  a  form  of 
distinct  gastralgia.  The  use  of  intestinal  antiseptics,  as  small 
doses  of  salol,  also  the  addition  as  a  digestant  of  os-gall,  gr.  i, 
and  extract  of  gentian,  gr.  ^,  a  half -hour  after  meals,  acted  effi- 
caciously, and  the  patient  has  gone  on  to  complete  cure  after  a 
prolonged  treatment  which  had  not  entirely  restored  her  equilib- 
rium when  she  left  for  the  country.  It  was  this  little  addition 
of  a  digestant  that  capped  the  climax  towards  cure.  She  gained 
fifteen  pounds  in  four  weeks. 

Another  case  of  Miss  P.,  aged  twenty-five,  a  very  intelligent 
young  woman,  was  a  most  persistent  case  of  neurasthenia,  greatly 
benefited  by  intestinal  antiseptic  treatment  in  addition  to  a  semi- 
rest  cure.  In  this  case  large  amounts  of  indican  were  found  in 
the  urine. 

Another  adjuvant  in  the  treatment  was  high  flushings  of  the 
colon  with  a  solution  of  lime-water,  and  it  was  interesting  to  see 
a  facial  acne  disappear  with  the  general  improvement  of  the  case, 
and  especially  after  resort  to' the  measures  mentioned.  The  reten- 
tion of  toxines  in  the  system  is  undoubtedly  a  factor  in  preventing 
many  cases  of  neurasthenia  from  reaching  fullest  health;  until 
this  detail  is  carried  out,  the  patient  will  never  become  well.  The 
writer  has  seen  good  results  in  the  treatment  even  of  epilepsy  by 
means  of  antiseptics  and  flushing  the  intestine  with  copiously  pure 
water  between  meals. 

Apropos  of  this  subject,  the  reader  is  also  referred  to  an  article 
by  Morris  de  Fleury  in  the  Bulletin  General  de  Therapeutique, 
November  23,  1900,  in  which  lie  gives  tables  showing,  in  the  Ex- 
cretion of  Urine  in  Neurasthenia,  the  amounts  of  uric  acid,  urea, 
and  phosphates;  the  earthy  phosphates  being  greatly  in  excess 
of  sodium  and  potassium.  Indican  or  skatol  was  foimd  73 
times  out  of  100.  The  coefficient  of  oxidation  was  decreased 
65  times  out  of  100;  the  increased  acidity  of  the  urine  and  density 


112  TREATISE    OX    XEPtVOUS    DISEASES 

of  the  same^  59  times  out  of  100  cases  recorded.  Such  data  as  this 
goes  to  prove  the  wide-sjDread  disturbance  of  metabolism  in  func- 
tional disease.  An  investigation  ^  by  the  writer  has  been  for  deter- 
mining the  same  conditions. 

The  treatment,  therefore,  will  more  and  more  depend  upon  the 
exact  knowledge  obtained  through  the  physiologic  and  pathologic 
study  of  chemistry,  it  seems  to  us,  for  the  permanent  cure  and 
prevention  of  these  ubiquitous  diseases;  so  that  while  the  gastro- 
intestinal tract,  the  great  laboratory  of  the  body,  may  be  second- 
arily affected  in  neurasthenia,  it  is  essential  to  treat  the  symptom 
as  well  as  the  fundamejital  condition  of  nerve-cell  exhaustion. 
Frequently  peptonization  of  the  large  quantities  of  milk  taken  will 
be  of  great  value  in  aiding  hypernutrition.  The  skilled  use  of 
massage  is  also  a  measure  which  will  help  metabolism  in  the  muscle 
itself,  as  well  as  by  mechanically  forcing  on  waste  products  and 
giving  vigour  to  the  circulation;  for  frequently,  in  these  cases, 
the  cardio-vascular  system  is  not  doing  the  physiologic  duty  re- 
quired. 

Excitement  of  an  unusual  nature  should  be  strictly  prohibited 
in  eases  of  neurasthenia,  and  this  is  especially  more  important  in 
the  convalescent  from  chorea.  In  the  latter  disease,  even  pleasur- 
able excitement  may  be  sufficient  to  cause  irritation,  and  relapse  to 
follow.  A  very  marked  instance  of  this  condition  of  things  was 
shown  in  the  case  of  a  minister's  daughter,  aged  fourteen,  coming 
under  my  care  on  ISTovember  6,  1900.  She  had  been  continuously 
in  choreic  movements  since  January,  1900,  having  been  somewhat 
improved  in  health  by  September,  1900,  when  she  started  to  school 
and  had  a  relapse.  The  slightest  pleasures  she  enjoyed  were  suffi- 
cient to  make  her  worse.  The  child  was  anaemic,  complained  of 
vague  pains  in  the  lower  extremities,  and  was  greatly  emaciated. 
The  use  of  Blaud's  pill,  5  grs.,  three  times  a  day,  of  salt  sponge- 
baths  at  night  and  of  arsenic  in  small  doses,  and  the*  insistence 
upon  the  use  of  woollen  underclothing,  by  July  3,  1901,  eight 
months  after  beginning  treatment,  brought  her  to  a  timely  cure 
— to  health  she  had  not  known  for  many  years.  This  case  is  de- 
tailed to  show  that  chorea  is  no  slight  disease  to  deal  with,  and 
that  it  should  be  studied  in  all  of  its  aspects  as  to  hygiene  for  the 
patient,  if  health  is  to  be  restored.    It  may  have  been  that  previous 

^Uric  Acid  Excretion  in  Neurasthenia,  Transactions  of  the   College  of 
Physicians  of  Philadelphia,  vol.  xxii,  1900. 


TREATME^^T    m    CONVALESCENCE  113 

failures  in  this  case  were  -due  to  a  lack  of  hygienic  precautions 
being  insisted  upon  to  the  parents,  Avho  were  perfectly  willing  and 
did  carry  them  out  when  so  forcibly  directed,  of  which  they  are 
the  greatest  appreciators  to-day. 

CLIMATOLOGY    OF    NERVOUS    DISEASE 

-Under  climatology  come  temperature,  humidity,  winds,  purity 
of  air,  rarefaction  of  air,  sunlight,  electricity,  soil,  woodlands,  and 
social  surroundings.  The  therapeutic  climate  is  one  which  im- 
proves functional  activity  or  increases  the  resisting  power  of  the 
organism.  Climatology,  the  medical  geography  of  climate,  is  to 
climatotherapy  what  materia  medica  is  to  therapeutics.  The  main 
use  of  climatotherapy  is  as  an  adjuvant  to  ordinary  therapeutics. 
Dr.  A.  Manquat,  of  Nice,  has  given  the  best  authoritative  study 
of  this  important  subject.^ 

Difficult  though  it  be,  certain  fundamental  facts  must  surely 
exist  and  are  being  gradually  worked  out.  The  writer  has  made 
some  studies  -  upon  the  climatology  of  neurasthenia,  finding  that 
one  of  high  winds  or  in  an  altitude  above  2,000  feet,  or  in  damp, 
low  countries,  is  bad  for  this  disease.  Moderately  high  altitude, 
2,000  feet,  is,  on  the  contrary,  desirable  in  sclerotic  cord  diseases, 
since  decreased  atmospheric  pressure  favours  better  circulation.  ' 

More  elemental  facts  to  be  recalled  are  that  air  at  sea  and  at 
high  levels  is  purest.  The  temperature  above  sea-level  diminishes 
about  1°  F.  for  every  300  to  400  feet,  and  is  less  the  drier  the 
air.  Temperature  of  air  varies  less  near  sea-level,  and  is  less  in 
the  southern  hemisphere.  The  higher  the  elevation  and  the  colder 
the  air  the  less  moisture  it  contains.  Ozone  and  electric  influences 
of  mountain  countries  are  apt  to  irritate  nervous  people.  AYeber 
speaks  of  marine,  low-level  inland  and  high-level  inland  as  the 
great  divisions  of  climate.  Warm  marine  climates  and  sea  voyages 
on  calm  water  are  best,  perhaps,  of  all  for  -neurasthenics.  High 
climates  are  best  for  anaemic  cases.  The  Eiviera,  low  Colorado, 
Canada  (in  summer)  are  the  most  desirable  climates  for  the  nerv- 
ous invalid.    Inland  Maine  is  also  of  value. 

'  Bulletin  medieale,  November  27  and  December  14,  18,  1901,  and  January 
1  and  8,  1902. 

2  Climatology  of  Neurasthenia,  Medical  News,  January,  1901,  and  Nervous 
Cardiac  Symptoms  due  to  High  Altitudes,  February  14,  1903. 


CHAPTER   V 
SYMPTOMATIC  DISORDERS 

VERTIGO 

Synonyms:  Dizzmess,  Giddiness,  etc. 

By  vertigo  we  understand  a  disturbance  of  consciousness,  char- 
acterized by  a  feeling  of  objects  moving  (objective  vertigo)  or  of 
a  sensation  of  the  person  moving,  which  is  termed  subjective  ver- 
tigo. 

Causes. — The  causes  of  vertigo  may  be  classed  somewhat  like 
those  of  headache:  (1)  Htemic — anaemia,  hypersemia,  etc.;  (2) 
toxic — tobacco,  alcobol,  lead,  etc.;  (3)  arterial  sclerosis;  (4)  acous- 
tic nerve  irritation;  (5)-  neuroses — neurasthenia,  epilepsy,  etc.; 
(6)  reflex — ocular,  gastric,  organic,  as  organic  brain  disease;  (7) 
mechanical  causes,  as  swinging,  sea-sickness,  car  sickness. 

Symptoms. — They  usually  come  on  suddenly,  and  last  but  for 
a  few  moments.  The  patient  may  have  the  sensation  of  rising 
or  sinking,  or  objects  moving  or  whirling  about  (the  objective 
form),  or  the  patient  himself  may  feel  as  though  he  was  revolving 
or  to  rise  and  fall  (subjective  form).  There  is  a  sense  of  alarm 
and  a  feeling  of  faintness.  Cerebration  is  disturbed  and  ideas  are 
confused.  There  may  be  nausea  or  vomiting.  The  patient  usually 
totters,  and  sometimes  falls.  It  may  be  due  to  certain  lesions  of 
the  cerebellum  and  its  peduncles,  or  of  the  labyrinth  of  the  inter- 
nal ear.  It  is  then  usually  associated  with  forced  movements. 
The  characteristic  of  vertigo  is  that  it  is  relieved  when  the  patient 
lies  supine.  This  is  the  opposite  condition  in  a  case  of  headache. 
(See  section  on  Headache.) 

A  large  proportion  of  the  vertigoes  met  with  are  due  to  dis- 
ease or  irritation  of  the  eighth  nerve  and  its  centres.  The  more 
common  cause  is  a  lesion  of  the  labyrinth  of  the  internal  ear. 
Vertigo,  therefore,  is  a  symptomatic  disease.  If  the  blood  is  debil- 
itated, anaemia,  or  if  the  patient  is  plethoric,  hyperaemia,  the  symp- 
toms of  this  affection  will  come  hand  in  hand  with  the  vertigo. 
114 


SYMPTOMATIC    DISORDERS  115 

If  the  disease  be  due  to  arterial  sclerosis,  which  produces  a  local- 
ized anemia  of  the  brain,  the  vertigo  will  then  be  associated  with 
symptoms  of  cerebral  arterial  sclerosis.  In  some  of  these  cases 
the  kidneys  are  also  affected  in  the  process,  and  we  have  the  symp- 
tomatology of  the  red-granular  kidney,  low  specific  gravity  to  the 
urine,  decrease  in  the  quantity  of  urea,  etc.  If  associated  with 
neuroses,  we  have  the  characteristic  symptoms  of  these  several 
affections,  such  as  neurasthenia  and  hysteria,  and  the  vertigo  will 
be  apt  to  present  exacerbations  commensurate  with  the  paroxysms 
of  the  several  diseases,  or  else  the  vertigo  will  be  more  exaggerated 
sequent  to  aggression  of  symptoms  of  the  neuroses  mentioned.  The 
reflex  vertigoes  will  be  associated  with  the  organ  that  is  particu- 
larly involved,  as  the  cause  of  the  irritation.  Thus  a  patient  suf- 
fering with  astigmatism  would  complain  of  the  eyes,  as  a  rule,  but 
not  always  so,  however.  The  patient  with  gastric  vertigo  would 
have  gastric  attacks  or  crises.  This  is  more  usual  in  persons  about 
middle  life.  From  organic  brain  disease  the  reflex  vertigo  would 
be  associated  with  some  pathologic  process  going  on  within  the 
cranium.  The  mechanical  causes  giving  rise  to  vertigo  will  be 
easily  enough  determined  by  the  careful  observation  of  the  physi- 
cian. Toxic  vertigoes  are  associated  with  sepsis  in  different  parts 
of  the  body,  or  are  from  drug  poisons,  such  as  tea,  lead,  coffee,  etc. 
Auto-intoxications  will  be  associated  frequently  with  the  finding  of 
indican  in  the  urine;  the  gouty  with  secretion  of  urea,  uric  acid, 
and  alloxuric  bodies,  and  other  end  products. 

Diagnosis. — The  differential  diagnosis  of  vertigo  would  depend, 
as  above  indicated,  by  noting  the  symptoms  of  the  several  diseases 
associated  with,  preceding,  or  following  the  attack. 

Prognosis. — This  depends  entirely  upon  its  duration  and  the 
ability  to  cure  the  cause.  HEemic  and  toxic  vertigoes  will  usually 
recover  if  treated  early.  Those  cases  due  to  arterial  sclerosis 'are 
very  bad  as  to  the  prognosis.  Those  due  to  neuroses  are  also 
difficult  cases  to  manage.  The  mechanical  vertigoes  will  subside 
with  abatement  of  the  cause. 

Treatment. — Quietude  is  an  essential.  This  will  depend  en- 
tirely upon  the  cause.  If  there  be  anaemia,  haematics  should  be 
administered,  such  as  tincture  of  chloride  of  iron  and  Blaud's 
pill.  If  due  to  plethora,  venesections,  or  better,  wet  cupping  or 
the  application  of  the  natural  leech,  will  often  prove  of  great 
value.  The  use  of  potassium  iodide  as  an  alterative  and  sorbefa- 
8 


116  TEEATISE    OX    XEBVOUS    DISEASES 

cient,  continued  in  small  doses,  often  produce  marked  ameliora- 
tion of  the  symptoms  on  any  case.  Xitrogiycerin  y^  gr.  t.  i.  d., 
or  spt.  of  gionoin,  5-minim  doses.  If  ear  disease  is  present,  the 
case  should  he  referred  to  a  competent  aurist  for  the  proper  diag- 
nosis and  treatment  of  the  condition. 

The  patient  should  lie  supine  during  an  attack. 


■     INSOMNIA 

This  is  sometimes  called  sleeplessness,  and  is  given  to  those 
conditions  of  insufficient  or  restless  sleep  or  to  the  entire  absence 
of  sleep  for  a  long  time.  Certain  persons  present  idios}Ticrasies 
as  to  the  amount  of  sleep  required.  Xapoleon  required  hut  a  few 
hours  out  of  twenty-four.  It  is  said  that  some  people  ca7i  go  with- 
out sleep  for  indefinite  periods,  as  long  as  two  or  three  weeks  at  a 
time,  cases  being  on  record  of  much  longer  times  of  the  waking 
state,  inflicted  as  a  punishment.  Eight  hours  in  twenty-four  is 
the  average  for  an  adult;  children  require  more. 

-  Causes. — The  male  sex  suffers  more  than  the  female  sex.  no 
doubt  due  to  employment  being  more  of  a  mental  nature  in  men 
than  in  the  majority  of  women.  Labouring  classes  are  less  liable 
to  insomnia  than  those  engaged  in  business  or  professional  pur- 
suits. It  is  frequently  hereditary,  no  other  exciting  cause  existing 
that  is  known.  It  is  also  seen  in  certain  diseases,  such  as  gout  and 
lithsemia,  etc.  Quite  probably  it  is  the  result  of  auto-intoxication. 
the  absorption  of  certain  ptomaines  or  leucomaines,  or  other  dia- 
thetic by-products.  Diseases  of  the  cardio-vascular  system  may 
lead  to  insomnia.  Poisons  may  also  cause  insomnia,  such  as  are 
seen  as  the  result  of  syphilis,  malaria,  chronic  nephritis,  or  other 
infectious  diseases,  lead-poisoning,  etc.  Those  cases  which  are 
not  due  to  definite  lesions  are  designated  functional :  for  instance, 
the  insomnia  of  neurasthenia  and  vaso-motor  disorders. 

The  time  of  the  sleeplessness  varies.  Some  persons  cannot 
sleep  during  the  early  hours  of  the  night,  and  others  will  awaken 
at  a  certain  time  and  cannot  sleep  thereafter.  In  children  it  is 
accompanied  by  much  mental  and  physical  disturbance,  such  as 
dreams,  physical  or  mental  excitement. 

The  patient  is  also  seen  to  be  irritable  from  the  loss  of  sleep, 
and  this  is  much  more  exaggerated  in  children  than  in  adults. 
Insomnia  from  neurasthenia  usually  presents  a  tumult  of  thoughts 


SYMPTOMATIC    DISOEDEES  117 

passing  through  the  mind  which  seem  to  prevent  sound  sleep; 
or  in  them  sleep  is  very  superficial,  the  patient  being  aroused 
very  easily  and  frequently  imagining  that  he  was  partially  awake 
during  the  sleeping  period.  In  this  form  the  patient  wakes  easily 
and  afterward  feels  "  draggy/'  as  though  he  had  had  no  rest  at 
all,  and  frequently  describing  the  sensation  as  though  he  was 
weaker  after  his  limited  sleep  than  before  the  time  when  he  went 
to  rest.  In  the  insomnia  of  adult  insane,,  there  is  a  still  greater 
degree  of  restlessness.  A  symptom  described  by  Weir  Mitchell  fre- 
quently occurring  just  at  the  prcedormium  is  a  sudden  jerking 
of  the  body,  which  arouses  he  patient  just  when  he  was  passing 
into  a  doze. 

PatJioIogy. — This  seems  to  be  as  yet  unknown.  It  is  very  likely, 
however,  that  there  is  a  variation  in  the  calibre  of  the  cerebral 
vessels,  causing  congestion,  due  to  a  weakness  of  the  sympathetic 
system.  "  Eetraction "  of  the  cerebral  neurones  is  also  given  as 
the  "  neurone  theory  of  sleep."  The  pathology  of  s3^mptomatic  in- 
somnia, due  to  organic  disease,  would  be  the  pathology  of  the 
disease  in  cjuestion,  as  a  chronic  meningitis,  cerebritis,  gummata, 
etc. 

Treatment  of  essential  insomnia,  so  called,  lies  often  in  the 
treatment  of  some,  general  disorder,  such  as  hj^steria  or  neuras- 
thenia. If  angemia,  lithgemia,  uremia,  or  other  toxic  influences 
exist,  they  must  be  removed  by  the  proper  remedies  for  these  con- 
ditions. Measures  for  the  relief  of  the  symptoms  themselves  should 
be  adopted,  and  the  patient  should  get  rid  of  worry  as  much  as 
possible.  The  use  of  the  constant  cold  douche  to  the  spine  from 
three  to  five  minutes,  followed  by  cold  sponging  of  the  body,  usu- 
ally produces  sufficient  reaction  to  cause  a  dilatation  of  the  su- 
perficial blood-vessels  to  induce  sleep.  The  overuse  of  the  hot 
bath  is  to  be  decried,  since  it  is  apt  to  weaken  the  patient,  and 
by  not  producing  proper  reaction  to  the  surface  will  allow  stag- 
nation of  the  blood  in  the  meninges.  The  methods  of  counting 
or  other  monotonous  occupations  will  sometimes  avail,  but  these 
are  of  doubtful  efficacy,  and  should  be  substituted  by  other  forms 
of  occupation.  The  patient  should  live  in  the  open  air  as  much 
as  possible,  and  particularly  in  those  localities  where  dry  winds 
prevail  and  at  low  altitudes.  Drugs  used  with  caution  are  bro- 
mides, 10  to  15  grains  at  bedtime  or  in  combination  with  chloral 
hydrate,  5  to  10  grains,  being  cautious  to  guard  the  heart  with 


118  TREATISE    0^^   KERTOUS    DISEASES 

the  use  of  the  latter  drug.  Trional  or  sulphonal  in  15-grain  closes 
in  hot  milk  are  the  best  hypnotics.  Hyoscyamus  in  some  instances 
is  efficacious.  Paraldehyde  in  drachm  doses  is  a  valuable  hypnotic 
in  insomnia  due  to  alcoholism.  Camphor,  opium,  and  the  evanes- 
cent drugs,  as  asafcetida,  musk,  valerian,  etc.,  are  all  of  value  in 
hysterical  or  neurasthenic  insomnia.  The  use  of  massage  and 
Swedish  movements  at  bedtime  are  measures  that  are  of  great 
value,  and  particularly  the  effleurage  to  the  face,  thus  producing  a 
quiet  effect  through  reflex  action  upon  the  cerebral  cortex. 

NEURALGIA 

This  is  a  type  of  pain,  shooting  in  character,  occurring  along 
the  course  of  a  sensory  nerve,  and  functional  or  toxic  in  nature. 
There  are  different  varieties  of  this  disease,  as  follows :  trigeminal, 
brachial,  sciatic,  cervical,  intercostal,  anterior  crural,  and  visceral, 
etc.  Reminiscent  neuralgia  is  that  which  exists  after  the  cause 
has  disappeared.    It  is  at  times  a  monohysterical  sign. 

Causes. — Common  predisposing  causes  of  this  condition  are 
early  adult  life,  debility,  and  hereditary  predisposition.  The  cliar- 
acter  of  the  pain  is  sharp  and  shooting  in  nature,  and  frequently 
accompanied  by  tender  spots  or  points  over  the  exit  of  the  nerve 
from  a  canal  (points  of  Yalleix),  although  firm  pressure  over  the 
site  of  the  pain  will  generally  give  relief.  Vaso-motor  and  secre- 
tory symptoms  may  occur. 

Facial  Neuralgia.- — This  is  induced  by  cold  exhausted  condi- 
tions, and  is  more  frequent  in  the  female  sex.  It  has  a  distinct 
hereditary  tendency.  The  attacks  come  on  at  irregular  intervals, 
and  involve  some  one  or  all  the  three  branches  of  the  fifth  nerve. 
The  pain  is  sharp-shooting  and  paroxysmal. 

Treatment. — This  consists  principally  in  the  protection  of  the 
surface  and  the  building  up  of  the  system,  and  for  the  attack  the 
use  of  analgesics,  such  as  phenacetine  and  antipyrine.  The  appli- 
cation of  warmth  to  this  in  the  shape  of  hot  water  is  sometimes 
a  means  of  relief.  The  use  of  cod-liver  oil,  to  build  up  the  system, 
is  a  valuable  adjunct.    Aconitia  in  yi-^^ -grain  doses  is  of  value. 

Tic  Douloureux. — This  is  a  most  severe  form  of  facial  neu- 
ralgia. 

Symptoms. — A  sense  of  numbness,  occurring  at  the  site  of  the 
branch  particularly  affected,  such  as  the  superior  maxillary  branch, 
finally  followed"  by  dull  pain,  which  soon  amounts  to  acute  suffering 


SYMPTOMATIC    DISOEDEES  119 

and  rather  spasmodic  in  nature.  In  the  height  of  the  paroxysm 
the  patient  is  in  most  exquisite  suffering,  all  the  branches  of  the 
fifth  nerve  being  involved.  There  may-be  an  ephemeral  blindness, 
occurring  on  the  side  affected.  An  attack  may  last  from  one  to 
two  hours  to  twelve  hours  or  even  longer.  There  may  also  be 
spasm  of  the  facial  muscles.  The  teeth  may  be  very  sensitive 
during  or  after  an  attack,  and  sometimes  the  pain  is  so  localized 
in  the  teeth  or  maxillae  that  the  physician  or  patient  may  think 
the  tooth  is  the  real  seat  of  the  disorder,  and  for  this  reason  many 
teeth  are  extracted.  The  frequency  of  paroxysms  varies  from  once 
a  day  to  once  in  several  weeks,  although  some  cases  may  go  much 
longer.  The  exciting  causes  are  worry,  overwork,  exposure  to 
draughts,  and  dampness. 

Diagnosis. — This  lies  between  this  disease  and  migraine,  but  the 
character  of  the  pain  in  the  two  diseases  is  essentially  different, 
and  there  is  not  the  nausea  and  vomiting  in  the  trifacial  neuralgia 
as  in  sick  headache.  The  type  of  pain  which  is  induced  by  these 
paroxysms  and  may  become  chronic  or  hallucinatory  is  an  exam- 
ple of  reminiscent  pain,  and  is  a  psychic  phenomenon  purely. 

Prognosis. — As  a  rule  it  is  unfavourable.  The  patient  seldom 
gets  entirely  well  after  the  disease  has  once  been  established. 
Some  few  cases,  however,  have  been  cured  when  treated  in  their 
incipiency. 

Pathology. — This  consists  in  subacute  neuritis  in  the  branches 
of  the  fifth  nerve,  also  degeneration  of  the  Gasserian  ganglion  in 
the  worst  cases. 

Treatment. — In  the  treatment,  examination  of  the  teeth  should 
be  a  point  in  order  to  determine  reflex  points  of  irritation.  Any 
other  irritants  about  the  face  should  be  eradicated.  For  the  par- 
oxysms of  pain,  the  use  of  analgesics  is  indicated,  as  phenacetine 
combined  with  caffeine.  Galvanism  by  placing  the  positive  pole 
over  the  painful  area  is  of  service.  At  times  a  hypodermic  injec- 
tion of  morphine  will  have  to  be  given  in  order  to  relieve,  although 
this  should  be  in  a  guarded  measure  in  the  treatment.  Cannabis 
indica  is  of  some  value  in  these  cases  when  given  in  prolonged 
small  dosage.  Cod-liver  oil  and  tonics,  with  the  use  of  iron  in 
angemic  cases,  is  very  good  treatment.  Excision  of  the  Gasserian 
ganglion  is  to  be  had  as  a  dernier  rcssort. 

Intercostal  Neuralgia. — This  is  a  form  in  which  the  pain  is 
limited  to  the  distribution  of  the  intercostal  nerves.    This  is  some- 


120  TEEATISE    ON    NERVOUS    DISEASES 

times  designated  pleurodynia.  The  pain  is  worse  on  movement 
of  the  side  or  in  the  ordinary  respiration  of  the  patient,  so  that 
it  is  frequently  called  "  a  stitch  in  the  side." 

Prognosis. — This  is  favourable. 

Treatment. — This  is  the  same  as  for  other  forms  of  neuralgia, 
plus  the  strapping  of  the  side  of  the  chest;  or  the  use  of  counter- 
irritation  by  means  of  the  use  of  the  actual  cautery  will  sometimes 
give  relief.  The  so-called  lierpes  zoster  is  the  type  in  which  we 
have  a  neuritis  of  the  intercostal  nerves  and  frequently  an  erup- 
tion, vesicular  in  character,  along  the  course  of  the  nerve.  This 
disease  seems  to  be  in  some  cases  infectious  in  nature,  and  is  more 
frequently  seen  in  childhood  than  in  adult  life,  it  also  very  fre- 
quently being  bilateral. 

The  treatment  of  herpes  zoster  does  not  differ  from  that  of 
other  forms  of  neuralgia  except  that  protection  to  the  eruption 
of  the  part  should  be  insured.  This  can  best  be  done  by  means  of 
oiled  silk  or  cotton  batting. 

Sciatic  Neuralgia. — This  is  neuralgia  of  the  sciatic  nerve. 
Some  doubt  the  existence  of  pain  in  the  sciatic  nerve  area  with- 
out there  being  an  active  inflammatory  lesion  present.  There  are 
a  certain  number  of  cases  in  which  the  increased  reactions  and 
exquisite  neuralgic  pain,  without  tenderness  on  pressure,  would 
lead  one  to  suppose  they  were  not  inflammatory. 

Prognosis. — This  is,  as  a  rule,  good. 

Treatment  consists  of  splinting  the  lower  extremity  during 
the  exacerbation  of  the  disease.  The  use  of  the  ordinary  reme- 
dies mentioned  above  is  indicated.  The  majority,  of  persistent 
cases  that  do  not  respond  to  the  treatment  outlined  are  really  of 
an  inflammatory  nature — a  neuritis.     (See  section  on  Neuritis.) 

Anterior  Crural  Neuralgia. — This  is  a  neuralgia  existing  along 
the  course  of  the  anterior  crural  nerve,  as  its  name  would  indicate. 
The  pain  shoots  down  through  the  outer  upper  aspect  of  the  thigh 
towards  the  inner  side  of  the  knee.  This  sometimes  is  induced 
by  lesions,  as  indeed  is  sciatic  neuralgia  in  the  pelvis,  such  as 
tumour,  growths  of  bone.  It  is  also  designated  parcestlietic 
neuralgia  when  the  distress  is  of  a  burning  sensation. 

Prognosis. — This  is  good  if  the  original  cause  can  be  relieved 
or  cured,  as  through  removal  of  a  tumour. 

Treatment. — This  is  the  same  as  for  the  other  forms  of  neu- 
ralgia, except  that  nerve  stretching  is  singularly  often  curative. 


SYMPTOMATIC    DISOEDERS  131 

Visceral  Neuralgia. — Gastralgia  is  one  of  the  most  important 
forms.  This  consists  of  pain  localized  to  the  epigastric  region. 
It  bears  no  relation  to  the  ingestion  of  foods  particularly,  ex- 
cepting that  it  is  at  times  relieved  by  taking  of  food.  The  dis- 
ease is  due  to  the  irritation  of  the  gastric  filaments  of  the  pneumo- 
gastric  nerve. 

Prognosis. — This  depends  upon  the  conditian  of  the  system. 
If  metabolism  improves  the  patient  usually  recovers. 

Treatment  consists  in  the  application  of  heat  to  the  epigas- 
trium, the  use  of  Fowler's  solution  in  gradually  ascending  doses, 
given  after  meals  (gtt.  iij  to  x  t.  cl.)  and  treatment  of  existent  neu- 
rasthenia.   The  use  of  repeated  blistering  I  have  seen  cure. 

Neuralgia  of  Heart. — This  consists  in  painful  paroxysms  about 
the  pra^cordia,  and  accompanied  by  a  subjective  feeling  of  pending 
death.  There  is  a  sense  of  constriction,  as  though  the  heart  was 
grasped  in  a  vice.  The  lips  become  pale,  the  pain  is  most  in- 
tense in  the  praecordia,  of  a  constricting  character,  and  frequently 
shoots  down  the  left  upper  extremity.  The  patient  becomes  cold 
and  clammy,  and  lies,  through  both  fear  and  inability  to  move 
on  account  of  the  pain,  in  a  position  of  iixity  of  the  entire  muscu- 
lature until  the  passing  of  the  spell,  which  may  last  from  three  to 
four  minutes  to  an  hour.  The  patient  after  the  attack  is  greatly 
weakened,  and  it  is  some  hours  before  the  sense  of  fear  and  the 
pain  subsides.  Angina  pectoris  recurs  without  definite  cause, 
although  exercise  may  induce  an  attack. 

Pathology. — Sclerosis  at  the  orifices  of  the  coronary  arteries 
with  narrowing  and  fatty  change  has  been  found. 

Prognosis. — This  is  absolutely  unfavourable. 

Treatment  consists  in  the  use  of  amyl  nitrate  inhalations  dur- 
ing an  attack,  nitroglycerin  over  continuous  periods,  and  the  relief 
of  arterial  sclerosis,  if  present,  by  the  use  of  potassium  iodide. 
Such  patients  should  live  a  quiet  life,  never  indulging  in  over- 
eating or  in  stimulation.  Mental  strain  should  be  avoided,  since 
this  is  one  of  the  patent  causes.  In  the  most  serious  attacks  hypo- 
dermic injections  of  morphine  may  be  necessary  to  relieve  the 
pain. 

HEADACHE 

This  is  a  condition  of  pain  in  the  head.  It  is  due  to  irritation 
of  the  fifth  nerve  branches.    The  characteristic  of  headache  is  that 


122  TREATISE    OX    XERY0U8    DISEASES 

it  is  usually  made  worse  when  the  patient  lies  down — i.  e.,  when 
the  head  is  lowered,  with  the  exception  of  anamic  headaches. 

Causes. — Overwork,  malaria,  and  other  infectious  diseases," 
poisonings  from  witiiout,  such  as  tea  and  various  drugs;  poisons 
from  within,  due  to  disturbance  of  metabqlism,  such  as  in  gout 
and  rheumatism,  anemia,  and  in  diseases  of  the  meninges.  Final- 
ly, headaches  are  due  to  organic  diseases  of  the  brain,  its  mem- 
branes, or  overlying  structures.     Some  types  of  headache  are : 

Boring,  often  described  as  though  a  nail  were  driven  into  the 
vertex,  the  so-called  lavus  of  hysteria. 

Shooting  or  neuralgic  headache,  which  is  parox3^smal  and  ex- 
tremely painful. 

Constriction  or  helmet-like  headache,  characteristic  of  neuras- 
thenia, consists  in  the  sensation  of  constriction  about  the  scalp 
with  vague  pain  through  the  top  of  the  head. 

Finally,  we  have  another  type  of  headache,  which  is  confined 
to  one  side  of  the  head,  and  is  called  migraine  or  megrim  or  hemi- 
crania. 

J.  C.  Wilson  gives  as  causes  of  headache : 

1.  Reflex  Irritation — viz.,  ocular  (e5^e-strain),  nasal,  pharyn- 
geal, auditory,  decayed  teeth,  reproductive  organs  (especially  fe- 
male), thoracic  and  abdominal  viscera. 

2.  Toxsemic. — A.  Infectioyis,  as  acute  infectious  diseases;  ma- 
laria. 

B.  Incornplete  or  perverted  physiologic-chemical  processes,  or 
the  defective  elimination  of  waste,  as  uraemia,  diabetes,  gout, 
lithsemia,  rheumatism,  gastro-hepatic  derangements,  constipation.  ■ 

C.  Action  of  drugs  and  poisons,  (a)  Acute :  nitrites,  quinine, 
opium,  alcohol,  carbon  dioxide,  etc.  (l)  Chronic:  lead,  tobacco, 
alcohol,  opium,  tea,  coffee. 

3.  Circulatory  Disturbances. — A.  Passive  congestion,  as  by  pos- 
ture ;  tight  clothing  about  the  neck ;  pressure  on  veins  by  tumours. 

B.  Active  hypercBmia,  from  excessive  physical  or  mental  strain ; 
early  stage  of  acute  meningitis. 

C.  Ancemia,  following  loss  of  blood  or  the  idiopathic  ansemias, 
especially  chlorosis. 

MIGRAINE  (Sick  headache,  megrim) 

Migraine  is  a  type  of  headache  which  is  so  distinctive  in  its 
phenomena  as  to  warrant  special  discussion.    There  is  a  hereditary 


SYMPTOMATIC    DISORDERS  123 

predisposition  very  strongly  manifest  in  this  disease.  First,  direct 
hereditary  predisposition  to  the  disease  itself  is  transmitted,  sec- 
ond, where  epilepsy  or  some  other  form  of  neurosis  exists  in  the 
ancestry.  The  characteristic  features  are  a  periodic  discharge  of 
sensory  impulse  from  the  sensory  nerves,  producing  pain.  The 
attack  itself  is  ushered  in  by  hallucinations  of  sight,  frequently 
accompanied  by  fortification  lines,  which  are  subjective  phenom- 
ena of  divergent  lines  appearing  before  the  eye  of  the  patient. 
Hemianopsia  may  develop.  The  pain  is  usually  first  manifest  in 
the  first  division  of  the  fifth  nerve,  and  the  pain  is  limited  to  one 
side  of  the  head  as  a  rule;  hence  the  name  of  hemicrania.  Soon 
after  the  onset  of  pain  there  is  nausea  and  vomiting,  the  patient 
becoming  very  sick  at  the  stomach  and  the  pain  reaching  extreme 
intensity  in  from  one  to  three  hours,  sometimes  associated  with 
a  spasm  of  the  muscles  on  the  affected  side  of  the  head.  The  at- 
tack itself  lasts  from  six  to  eight  hours,  when  the  pain  gradually 
subsides,  leaving  the  patient  in  a  weakened  condition,  from  which 
it  takes  him  some  days  to  recover  full  vigour.  There  is  never 
loss  of  consciousness  during  the  attack,  but  at  times  the  exhaus- 
tion so  closely  simulates  an  abeyance  of  the  mental  state  that 
epilepsy  is  with  difficulty  differentiated  from  migraine,  some  au- 
thors claiming  that  there  is  a  direct  relation  between  the  two  dis- 
eases. The  attack  of  migraine  comes  on  periodicall}^,  and  the  pa- 
tient may  have  recurrences  once  a  week  or  once  a  month,  and  in  the 
female  at  the  menstrual  epoch,  or  less  frequently.  The  attacks 
seem  to  be  induced  by  overeating,  auto-intoxication,  and  infectious 
diseases,  such  as  malaria,  etc. 

Prognosis. — This  is  very  indefinite.  A  guardedly  good  prog- 
nosis can  be  made  in  cases  where  there  is  not  a  history  of  direct 
heredity  and  in  those  of  good  constitution. 

Pathology. — This  has  not  as  yet  been  definitely  determined. 
So  far  as  we  know,  it  is  a  functional  disorder,  consisting  of  peri- 
odic discharge  from  the  sensory  cortical  neurones,  as  already  men- 
tioned. 

Treatment. — This  consists  of  measures  between  the  attacks  and 
during  the  attacks.  The  emunctories  should  be  kept  in  good  con- 
dition, the  liver  and  kidneys  active.  Any  diathetic  diseases  should 
be  treated,  such  as  rheumatism,  gout,  etc.  Carlsbad  salts  or  Ro- 
chelle  salts  are  of  value  to  keep  the  bowels  in  a  soluble  condition 
and  for  the  elimination  of  toxines.    Salol,  in  2-grain  doses  t.  i.  d.. 


124  TREATISE    0¥    NERVOUS    DISEASES 

is  of  value  here.  For  the  attack  itself,  phenacetine  is  a  valuable 
remedy,  given  in  5-grain  doses,  repeated  three  to  four  times  each 
da}'',  and  if  not  effective  can  be  substituted  by  other  analgesic  drugs, 
such  as  antipyrine.  The  use  of  tincture  of  cannabis  indica  is  of 
value  in  some  cases,  and  should  be  given  in  small  doses,  3  drops 
t.  i.  d.,  gradually  increased  to  the  physiological  limit.  In  the  worst 
attacks  hypodermic  injection  of  morphine  may  have  to  be  resorted 
to,  but  this  must  be  guarded,  else  the  drug  habit  may  be  brought 
about. 

MENIERE'S    DISEASE 

This  is  a  persistent  neurosis  in  which  vertigo  is  one  of  the  most 
important  symptoms.  There  is  also  irritation  or  disease  of  the 
eighth  nerve  or  its  centres.  The  inner  ear  is  usually  affected  in  tlie 
labyrinth.    Deafness  is  progressive  from  the  first. 

Symptoms. — These  are  of  the  most  exaggerated  type  of  vertigo 
where  other  causes  are  excluded,  excepting  disease  resident  in  the 
internal  ear  and  where  vertigo  is  associated  with  extreme  nausea 
and  attacks  of  syncope.  In  this  form  of  vertigo,  too,  the  pro- 
gressive deafness  and  tinnitus  aurium  accompanied  by  forced 
movements,  staggering  gait,  or  absolute  inability  to  walk,  due  to 
the  dizziness  in  the  worst  cases,  each  time  the  patient  arises  from 
the  horizontal  position,  are  all  diagnostic.  The  course  of  the  dis- 
ease is  downward  from  the  very  first,  the  patient  usually  failing  in 
general  health  on  account  of  the  extreme  distress  and  inability  to 
retain  food.  Deafness  becomes  profound  as  the  disease  progresses, 
and  when  complete  deafness  is  present  the  vertigo  ceases  on  ac- 
count of  the  destruction  of  the  auditory  centres  of  equilibrium 
which  have  been  irritated. 

Diagnosis. — This  is  not  difficult  if  the  above  points  in  symp- 
tomatology are  carefully  remembered. 

Prognosis  is  guarded  even  in  cases  where  the  deafness  is  only 
slight  and  the  disease  not  too  far  advanced.  TJsually  the  deaf- 
ness becomes  absolute  when  vertigo  ceases  and  the  patient  is  much 
better  in  general  health. 

Treatment. — The  treatment  indicated  above  for  vertigo  is  em- 
ployed. A  drug  which  is  harmful  in  the  ordinary  cases  of  vertigo, 
but  is  of  value  in  these  cases,  is  quinine.  This  is  given  in  small 
doses  and  then  increased  until  cinchonism  results,  the  drug  then 
being  withheld  for  a  time  and  renewed  at  intervals  in  fairly  large 


SYMPTOMATIC    DISOEDERS  135 

ph3'siological  closes.  Opium  has  been  recommended  in  this  disease, 
but  this  should  be  used  guardedly  on  account  of  the  danger  of 
the  drug  habit.  Hydrobromic  acid  in  the  form  of  a  syrup,  given 
30  drops  a  day,  or  the  usual  bromide  salts  in  moderate  doses,  or 
salicylate  of  soda,  5-grain  doses,  t.  i.  d.,  will  be  of  great  service 
in  these  cases.  Sinkler  recommends  ergot.  Hirt  recommends 
hypodermics  of  10  dropg  of  a  2-per-cent  solution  of  pilocarpine. 
Bromides  given  in  large  doses  (gr.  xl,  t.  i.  d.)  have  been  recom- 
mended. 


CHAPTEE    VI 
CRANIAL   NERVES 

DISEASES    OF   THE    CRANIAL    NERVES 

Olfactory. — This  nerve  may  be  affected  either  by  irritative  or 
destructive  lesions.  If  the  former,  such  as  a  tumour  pressing  on  a 
nerve,  it  may  produce  besides  the  symptoms  of  the  growth  hyper- 
osmia.  Destructive  lesions,  as  continued  pressure  of  the  tumour 
or  a  neuritis  of  the  nerve  filaments,  would  produce  anosmia.  Per- 
version of  the  sense  of  smell,  or  parosmia,  may  be  a  symptom  in 
certain  progressive  diseases  of  the  olfactory  nerves  or  centres.  A 
fracture  at  the  base  of  the  skull  may  be  the  cause  of  anosmia,  as 
in  a  case  of  a  woman  seen  under  my  care,  where  there  were  no 
other  symptoms,'  and  in  which  an  injury  seems  to  have  been  the 
exciting  cause.  A  case  reported  by  S.  Weir  Mitchell  in  his  Clin- 
ical Lessons  on  N"ervous  Diseases,  I  have  also  had  the  pleasure 
of  studying,  but  in  addition  to  this  the  woman  had  hysterical  stig- 
mata, including  amblyopia  and  disturbance  of  the  sense  of  taste. 

Diagnosis  and  Prognosis. — Disease  of  the  olfactory  nerve  can- 
not be  confused  with  other  diseases,  since  the  specificity  of  the 
condition  is  clear.  The  prognosis  would  depend  largely  upon  the 
lesion  discovered  and  the  possibility  of  regeneration  of  the  nerve  in 
these  cases. 

Treatment  consists  in  treating  the  cause. 

Optic. — Affections  of  this  nerve  consist  of  functional  amblyo- 
pias and  organic  diseases,  such  as  choked  disk,  optic  neuritis,  etc. 

Optic  neuritis  occurs  in  85  per  cent  of  the  brain  tumours,  so 
that  diseases  of  this  nerve  can  be  expected  in  that  proportion  in 
cases  of  brain  tumour,  and  when  found  would  be  suspicious  of 
the  presence  of  a  neoplasm  within  the  cranial  cavity.  Atrophy 
of  the  optic  nerve  is  either  primary  or  secondary.  The  sclerotic 
diseases  frequently  have  as  a  symptom  atrophy  of  the  optic  nerve, 
126 


CEANIAL   NEEVES  127 

such  as  in  tabes ;  and  secondary  atrophy  of  the  nerve  would  be 
that  sequent  upon  neuritis,  usually  preceded  by  choked  disk. 
Hemianopsia  is  a  neurologic  symptom,  and  is  more  frequently  due 
to  lesions  in  the  tracts,  usually  unilateral.  When  the  lesion  is  well 
back  of  the  chiasm  (as  far  as  the  primary  optic  centres),  the  centre 
for  contraction  of  the  pupil  when  light  is  thrown  upon  the  retina 
is  wanting,  hence  Wernicke  s  pupillary  inaction  will  be  found.  If 
the  lesion  causing  hemianopsia  is  back  of  the  thalamus,  the  centre 
not  therefore  destroyed,  the  Wernicke's  sign  will  not  be  present. 
The  test  for  this  important  sign  is  made  as  follows :  Throw  a  ray 
of  light  in  a  darkened  room  upon  the  unsound  side  of  the  retina; 
it  will  not  cause  the  normal  contraction  of  the  pupil  for  the  reason 
given;  whereas,  as  soon  as  the  ray  of  light  impinges  on  the  sound 
side  of  the  retina,  contraction  of  the  pupil  takes  place  immediately. 
This  is  the  most  delicate  test,  and.  has  been  by  some  writers  thought 
impossible  to  make  accurately,  although  admitting  the  scientific 
relation  of  the  symptom  to  the  disorder  in  question. 

Other  forms  of  hemianopsia  are  hinasal,  which  condition  is 
extremely  rare,  and  is  due  to  a  double  lesion,  involving  the  outer 
fibres  of  the  tracts  as  they  pass  to  become  a  component  of  the  optic 
nerves  proper  on  their  respective  sides.  Bitemporal  hemianopsia  is 
usually  the  result  of  a  tumour  of  the  pituitary  body,  which  de- 
stroys the  anterior  fibres  of  the  commissure,  passing  to  the  inner 
side  of  the  retina.  Hence  in  acromegaly  where  the  pituitary  is 
frequently  found  diseased  that  the  symptom  of  bitemporal  hemia- 
nopsia may  exist.  Hemianopsia  may  also  be  horizontal,  as  where  a 
tumour  or  other  lesion  affects  one-half  of  the  nerve  or  tract  above 
or  below,  destroying  it  or  its  function,  and  producing  blindness  in 
the  upper  or  lower  fields  of  vision.  This,  however,  is  a  very  rare 
affection  (for  illustration,  see  Fig.  19). 

Hemiopia  should  he  explained  here,  since  it  refers  to  the  side 
of  the  retina  blinded.  For  instance,  right  lateral  hemiopia  implies 
disease  of  the  retina  on  the  right  side,  whereas  it  means  in  terms 
of  hemianopsia  blindness  in  the  left  field. 

Treatment. — Treatment  of  the  diseases  of  the  optic  nerve  con- 
sists in  treating  the  underlying  conditions  when  bearing  upon 
nervous  diseases.  Optic  atrophy  seems  sometimes  to  be  benefitted 
by  the  use  of  electricity,  passing  6  or  8  milliamperes  of  the  gal- 
vanic current  through  the  head,  with  the  negative  pole  at  the  occi- 
put and  positive  placed  over  the  eyelids.     This  done  two  or  three 


128 


TREATISE    OX   XEEYOUS    DISEASES 


times  a  week  (a  three  to  five  minutes  application)  will  often  be  of 
some  benefit  to  the  patient.  Conditions  of  errors  of  refraction, 
muscular  unbalance,  etc.,  are  entirely  in  the  province  of  the  oph- 
thalmologist, who  should  be  consulted  in  all  such  cases.  A  dis- 
ease in  one  of  the  optic  nerves  and  closely  allied  to  diseases  of  the 
nervous  system  is  cataract,  since  this  insidious  blinding  of  a  person 
may  lead  to  general  nervousness  and  even  melancholia,  which 
should  be  looked  after  in  all  such  cases  with  the  idea  for  relief 
through  extraction  of  the  cataract. 

Oculomotor. — Paresis  of  the  third  nerve  produces  nystagmus, 
protrusion  of  the  eyeball,  and  ptosis.  There  are  two  types  of  pa- 
ralysis of  the  third  nerve — one  in 
which  the  external  muscles  alone 
are  involved  in  the  palsy  and  to 
which  the  name  external  ophthal- 
moplegia is  applied,  and  second, 
where  the  internal  muscles  of  the 
eyeball  are  paralyzed,  designated 
internal  ophthalmoplegia. 

The  causes  are  basilar  men- 
ingitis, syphilis,  and  neuritis  of  the 
nerve  and  trauma  as  in  some  cases 
of  fracture  of  the  base  of  the 
skull.  If  the  cause  of  the  lesion  is 
recent  tertiary  syphilis,  the  prog- 
nosis can  be  considered  fairly  good. 
If  it  is  an  evidence  of  parasyphi- 
litic  intoxication,  the  treatment  is 
not  of  much  avail.  Instances  of  basilar  meningitis  are  guarded  as 
to  the  prognosis,  since  no  one  can  tell  how  much  destruction  will 
result  in  incipient  paresis  of  the  nerve  from  the  jDressure  that  is 
produced. 

Diagnosis. — This  could  not  be  confounded  with  any  other  con- 
dition, if  the  movements  of  the  eyeball  in  relation  to  the  anatom- 
ical and  physiological  condition  of  the  eye  are  carefully  studied, 
external  strabismus  being  the  most  prominent  symptom  besides 
the  ophthalmoplegia  already  mentioned  above. 

Treatment. — This  consists  in  treating  the  original  etiological 
factor.     Potassium  iodide  in   doses   of   10  to   30   or   100   grains 


Fig.  '25. — Congenital  Nystagmus 
(mother  also  affected). 


CRANIAL    NERVES  139 

t.  i.  cl.  is  usually  one  of  the  most  valuable  treatments  if  persisted 
in  early  in  all  acute  cases.  Later,  after  the  absorption  of  the  exu- 
date has  taken  place,  the  use  of  strychnine,  if  generally  indicated. 
If  fracture  of  the  skull  occurred  and  the  nerve  was  severed,  there 
cannot  be  any  hope  for  amelioration,  since  operation  could  not 
reach  the  site  of  the  trouble  without  being  the  cause  of  death  in 
itself. 

-  Patheticus. — The  palsy  of  this  nerve  is  due  to  either  neuritis, 
meningitis,  or  trauma.  It  causes  paralysis  of  the  superior  oblique 
muscle;  the  eye  is  permitted  to  turn  upward  and  inward.  If  the 
condition  is  dependent  upon  a  neurological  lesion,  as  indicated 
above,  treatment  would  come  under  that  of  the  neurologist,  and 
would  consist  in  the  administration  of  iodides,  and  later  strych- 
nine. The  ophthalmologist,  as  in  all  diseases  of  special  nerves  of 
the  eye,  should  be  consulted  in  order  to  determine  any  special 
treatment  of  the  eye  affection  itself.  Isolated  palsy  of  the  fourth 
nerve  is  rare. 

Trifacial. — This  is  one  of  the  most  important  nerves  in  the 
affections  of  same,  from  a  neurological  point  of  view ;  since  diseases 
of  this  particular  nerve  produce  more  suffering  and  occur  more 
frequently  in  neurotic  individuals  than  in  any  other  nerve.  The 
cortical  centre  of  this  nerve  is  in  the  anterior  part  of  Broca's 
convolution,  the  lower  centre  being  in  the  floor  of  the  fourth  ven- 
tricle. The  lesions  producing  diseases  of  the  fifth  nerve  are  either 
central  or  peripheral;  excepting  in  some  few  cases  of  cortical  dis- 
eases where  the  lesion  is  supranuclear.  There  would  not  be  the 
reaction  of  degeneration  in  any  degree  of  destruction  of  this  cen- 
tre, whereas,  if  peripheral  parts  of  this  nerve  are  involved,  degen- 
eration of  the  branches  would  occur.  This  is  a  distinctive  point 
in  regard  to  all  the  cranial  nerves,  and  must  be  carefully  studied  in 
making  diagnosis  of  a  given  case.  Neuralgia  of  the  fifth  nerve  is 
the  most  common  disease  affecti'ng  it.  Tic  douloureux  has  been 
mentioned  under  the  head  of  separated  diseases  (see  Neuralgia,  p. 
117).  The  simple  neuralgia  of  the  fifth  nerve  would  be  looked  for 
in  the  different  branches,  acceording  to  the  site  of  the  disease,  which 
has  already  been  mentioned  under  the  proper  heading  (see  p.  117). 
It  should  be  especially  noticed  in  diseases  of  the  inferior  maxil- 
lary branch,  it  having  a  motor  fibre  as  well  as  motor  symptoms. 

Abducens. — Paralysis  of  the  sixth  nerve  produces  internal  stra- 
bismus.    This  is  frequently  due  to  neuritis,  not  an  unusual  lesion. 


130 


TREATISE    OX    ^teryOUS    DISEASES 


The  treatment  ^vollld  be  for  the  neuritis,  and  further,  the  case 
should  be  referred  to  the  ophtlialmologist  for  an  operation  upon 
tlie  muscles  affected  if  degeneration  has  occurred. 

Facial.^ — This  is  affected  from  supranuclear  or  infranuclear 
disease.  In  disease  of  the  cortical  centre,  which  lies  in  the  lower 
Rolandic  region,  there  will  be  primar}'  facial,  spasm  and  secondary 
paralysis  without  degeneration.  Here  the  lesion  is  generally 
unilateral,  with  the  spasm  or  paralysis  of  the  muscles  opposite; 

the  corrugator  super- 
cilii  muscle  not  being 
affected.  Nuclear  le- 
sions are  generally 
bilateral,  usually 
hemorrhage  or  gum- 
mata  involving  the 
floor  of  the  fourth 
-^entricle.  The  symp- 
toms would  be  pri- 
marily spasm  of  the 
muscles,  and,  finally, 
paralysis  with  wast- 
ing and  reaction  of 
degeneration.  The 

peripheral  lesions  of 
the  seventh  nerve, 
which  j)roduce  symp- 
toms of  seventh-nerve 
disease,  are,  first,  the 
intracranial ;  second, 
intra-osseous ;  and 
third,  extra-osseous  or  extra-cranial.  The  lesions  anywhere  along 
the  tract  indicated  in  90  per  cent  of  cases  are  unilateral.  They  are 
all  termed  peripheral  lesions,  since  they  are  not  in  the  centre  itself. 
And  the  paralysis  is  designated  Bell's  palsy.  The  extra-osseous 
form  of  peripheral  disease  is  frequently  excited  by  exposure  to  cold 
and  draughts  (neuritis),  or,  as  in  rare  eases,  due  to  trauma. 
Such  a  case  the  author  has  reported  in  a  girl  where  a  pipe  stem 
entered  immediately  below  the  helix  of  the  ear,  where  it  lay  buried. 
The  onset  of  symptoms  in  the  so-called  idiopathic  cases  is,  as 


Fig.  26. — Facial  Palst,  Left  Side, 

Showing  secondary  spasm  same   side,  and  inability 
to  dose  left  eye. 


CEANIAL    NERVES  131 

a  rule,  sudden,  the  patient  perhaps  waking  in  the  morning  and 
finding  the  face  drawn  to  the  well  side.  The  wrinkles  have  disap- 
peared from  the  paralyzed  side,  the  mouth  is  drawn  towards  the 
(Fig.  26)  opposite  side,  and  the  patient  is  unable  to  wrinkle  the 
brow  as  well  on  the  affected  side,  saliva  dribbles  from  the  mouth; 
there  will  be  inability  to  maintain  the  bolus  of  food  between  the 
teeth,  and  also  some  difficulty  in  deglutition.  The  patient  may 
also  complain  of  a  sense  of  pargesthesia  or  numbness  on  the  affected 
side,  but  there  is  rarely  anesthesia,  in  AA'-hich  case  the  neuritis  has 
involved  the  fifth-nerve  branches  as  well,  No  disturbance  of  the 
sense  of  taste  exists.  The  duration  of  this  type  is,  on  the  average, 
from  six  weeks  to  three  months,  and  depending  upon  the  amount 
of  neuritis  and  destruction  of  the  nerve-fibres  will  recovery  take 
place  completely,  perhaps  in  50  per  cent  of  the  cases  fully.  The 
intra-osseous  portion  of  the  nerve  is  involved  in  some  of  the  so- 
called  idiopathic  cases  of  Bell's  palsy,  but  is  much  more  often 
affected  when  the  patient  gives  a  previous  history  of  otitis  media ; 
although  this  might  be  the  predisposing  cause  to  the  extracranial 
form  in  rare  cases.  But  with  the  history  of  ear  disease  the  disturb- 
ance of  the  sense  of  taste  should  be  looked  for,  and  will  also  be  fre- 
quently found.  Taste  will  be  absent  or  lessened  on  the  anterior 
two-thirds  of  the  tongue  on  the  affected  side  in  such  cases,  due  to 
catching  of  the  chorda-tympani  nerve  as  it  passes  out  through  the 
hiatus  Fallopii.  The  testing  for  deafness  should  also  not  be  for- 
gotten, and  this  would  be  an  important  point  in  determining  the 
site  of  the  lesion,  since  if  aerial  induction  of  the  tuning-fork  is  bet- 
ter through  the  external  auditory  meatus  than  when  the  fork  is  ap- 
plied to  the  temporal  bone,  the  deafness  is  due  to  internal  ear  dis- 
ease; whereas  if  the  conduction  is  better  through  the  bone  than 
by  the  external  auditory  meatus,  the  disease  causing  the  deafness 
and  the  disturbance  of  taste  is  resident  in  the  middle  ear.  Intra- 
cranial disease  is  associated  with  deafness  or  vertigo,  the  latter 
being  a  prominent  symptom  where  the  semicircular  canals  are  in- 
volved, and  deafness  where  the  vestibular  portion  is  the  original 
seat  of  disease.  In  any  case  the  degeneration  of  the  seventh  nerve 
will  be  found  after  the  tenth  day.     Prognosis  is  uncertain. 

Treatment.— In  any  form  of  Bell's  palsy  the  treatment  of  the 
underlying  cause  is  of  prime  importance,  while  the  prognosis  will 
be  good  in  proportion  as  this  cause  is  determined  and  can  be  suc- 
cessfully eradicated;  thus,  if  a  meningitis  can  be  controlled  early, 


132  TEEATISE    ON    NEEVOUS    DISEASES 

very  likely  the  patient  will  recover  the  full  use  of  this  cranial  motor 
nerve.  Cases  clue  to  internal  or  to  middle-ear  disease  are  more 
serious,  since  the  exciting  or  predisposing  cause  is  the  difJicuU 
condition  to  remedy.  -  Such  a  case  should  be  referred  early  to  an 
aurist  for  proper  treatment.  Idiopathic  cases  are  best  treated  by 
applying  a  blister  back  of  the  ear,  keeping  the  patient  quiet,  adminis- 
tering a  purge  and  carefully  searching  for  any  other  cause.  The 
use  of  potassium  iodide  should  be  had  early,  and  in  fairly  large 
dosage  (from  10  to  15  grains  t.  i.  d.),  over  a  continuous  period  of 
two  to  four  weeks,  when  the  dose  should  be  gradually  lessened. 
A  smaller  dosage  should  then  be  continued  for  a  fortnight,  and 
finally  the  patient  put  under  the  tonic  influence  of  strychnine,  3V 
of  a  grain  t.  i.  d.  The  use  of  galvanism  should  be  instituted  by  the 
tent:h  day  or  second  week  after  the  onset  of  the  disease.  (See 
Electricity,  p.  97.)  This  is  the  most  valuable  agent  in  the  success- 
ful treatment  of  Bell's  palsy. 

Auditory. — Disease  of  the  eighth  nerve  proper  consists  of  tin- 
nitus aurium,  due  to  irritation  of  this  nerve;  and  deafness,  due 
to  destruction  of  the  nerve-trunk  or  its  centre.  Certain  forms  of 
paralysis  of  the  seventh  nerve,  as  shown  in  the  preceding  para- 
graphs, may  complicate,  but  they  need  not  be  rehearsed  here. 

Prognosis  of  eighth-nerve  disease  depends  upon  the  nature  of 
the  disease  within  the  temporal  bone  or  whether  the  nerve  or  its 
centre  is  involved;  in  the  latter  treatment  would  be  of  little  or 
no  avail,  whereas  in  peripheral  trouble,  as  in  middle  and  external 
ear  disease  probably  much  relief  or  cure  by  an  experienced  aurist 
may  be  brought  about.  A  disease  in  which  the  eighth  nerve  is 
particularly  involved  is  caled  Meniere's  disease.  (See  Symptom- 
atic Disorders). 

Glosso-pharyngeal.  —  The  glosso-pharyngeal  nerve  supplies 
motor  and  sensory  fibres  to  the  pharynx,  the  larynx,  back  part  of 
the  tongue,  and  sends  a  branch  (Jacobson's  nerve)  to  the  middle 
ear.  It  is  also  one  of  the  special  sense  nerves  of  taste.  (The 
chorda  tympani  supplies  the  anterior  tAVO-thirds  of  the  tongue.) 

Disease  of  this  nerve  would  produce,  if  irritated,  an  increase 
of  sensibility  in  the  pharynx  and  hypergeusia,  whereas  the  de- 
struction of  the  nerve  would  produce  loss  of  sensibility,  with 
ageusia,  on  the  posterior  third  of  the  tongue.  Disease  of  this 
nerve  is  usually  of  central  origin,  and  the  prognosis  and  treatment 
would  depend  upon  the  nature  of  the  setiologieal  factor  of  the 


CRANIAL    NERVES  133 

primary  disease.  Usually  in  disease  of  the  ninth  nerve  ameliora- 
tion is  doubtful. 

Diagnosis. — This  cannot  be  confused  with  any  other  lesions  of 
any  of  the  other  cranial  nerves,  when  one  remembers  the  anatom- 
ical distribution  of  same  and  its  function.  Treatment  is  of  avail 
only  as  the  cause  can  be  got  rid  of. 

Pneumogastric. — This  nerve  has  its  origin  behind  the  olivary 
body  of  the  oblongata  superficially,  and  has  its  deep  origin  in  the 
floor  of  the  fourth  ventricle  in  close-  conjunction  with  the  centre 
of  the  glosso-pharyngeal  nerve.  It  supplies  the  sensory  and  motor 
fibres ;  through  the  auricular  branch,  passing  to  supply  sensation  to 
the  external  ear,  and  a  pharyngeal  branch  supplying  motion  to  the 
pharynx.  There  are  also  the  laryngeal  branches,  of  which  the 
superior  supplies  sensation  to  the  larynx  and  ^notion  to  the  crico- 
thyreoid  miuscles.  The  inferior  or  recurrent  branch  is  entirely 
motor,  and  supplies  the  intrinsic  muscles  of  the  larynx,  excepting 
the  crico-thyreoid.  Then  there  are  also  the  cardiac  fibres,  the 
pulmonary  and  sensory,  the  oesophageal,  and  gastric  motor  fibres. 
Disease  of  this  nerve,  therefore,  produces  wide  symptomatology, 
varying  from  the  absence  of  sensation  to  the  external  ear  to  paral- 
ysis of  the  pharyngeal  muscles,  oesophageal,  stomach,  and  laryngeal 
muscles,  and  even  paralysis  of  the  heart;  so  that  in  the  majority  of 
cases  of  disease  of  this  centre  or  nerve  itself  death  results  from 
heart  failure  before  any  other  special  symptoms  could  come  to  the 
attention  of  the  physician.  Many  vague  symptoms  in  the  thoracic 
cavity  are  due  to  a  neuritis  of  the  various  branches  of  this  nerve. 
As  a  rule,  diagnosis  is  not  made  until  the  final  symptoms  develop 
and  the  patient  is  carried  ofl'  by  heart  failure.  The  treatment 
would  consist  in  eliminating  causes,  such  as  intoxications  or  men- 
ingitis or  polioencephalitis.     Strychnine  may  be  of  service. 

Spinal-accessory. — This  nerve  has  its  superficial  origin  from 
behind  the  olivary  body,  and  its  deep  origin  below  that  of  the 
tenth  nerve,  in  the  floor  of  the  fourth  ventricle,  making  its  exit 
through  the  jugular  foramen  and  supplying  motion  to  the  sterno- 
mastoid  muscle,  and  it  also  gives  motor  branches  to  the  tenth  nerve. 
Disease  of  this  nerve  is  usually  of  an  irritative  nature,  due  to  func- 
tional disturbances  of  the  centre,  resulting  in  spasmodic  wry-neck 
(Fig.  27)  or  torticollis.  In  this  affection,  which  usually  has  its 
onset  in  early  childhood,  and  is  sometimes  due  to  rheumatic  taint 
or  to  catching  cold,  drawing  of  the  head  forward  and  towards  the 


134 


TREATISE    0^    KEEYOUS    DISEASES 


affected  side  occurs,  the  chin  being  pushed  to  the  opposite  side.    It 
is  paroxysmal,  although  there  is  a  persistent  tonic  contraction  of 

the  muscles.  If  the  tra- 
pezius is  also  affected, 
there  will  be  elevation 
of  the  shoulder  of  the 
affected  side.  It  is  a  very 
chronic  disease,  and  may 
last  for  years.  iSTo  defi- 
nite pathology  has  as  yet 
been  discovered  in  the 
majority  of  cases.  Some 
are  distinctly  hysterical, 
as  proved  by  the  fact 
that  mental  therapeutics 
often  cure  the  condition. 
If  it  occurs  in  early 
childhood,  it  may  deform 
the  chest  and  neck  of 
the  patient  so  much  that 
the  deformity  is  a  very 
important  disability. 

Prognosis. — This  is 
therefore  very  dubious. 
Treatment. — Both  medical  and  surgical  measures  are  to  be  re- 
ferred to;  medical  in  the  administration  of  antispasmodics,  such 
as  tincture  of  gelsemium  or  conium,  gtt.  v,  t.  i.  d.  Surgical,  which 
consists  in  the  excision  of  the  nerve  in  whole  or  in  part.  Some 
surgeons,  as  Keen,  of  Philadelphia,  recommend  the  excision  of  the 
cervical-spinal  sensory  roots.  This  I  have  seen  cure  one  patient. 
Others  have  been  operated  on  with  the  reappearance  of  the  de- 
formity. The  patient  should  have  a  change  of  environment,  and 
he  should  live  in  quietude.  Proper  gymnastics  and  chest  expan- 
sion exercises  are  especially  necessary  in  young  persons.  Appa- 
ratus is  occasionally  of  service  in  relieving  contractures. 

Hypoglossal. — The  cortical  centres  are  in  the  lower  part  of  the 
central  convolutions.  This  nerve  has  its  superficial  origin  in  the 
front  part  of  the  oblongata  and  the  deep  origin  in  the  floor  of  the 
fourth  ventricle,  and  passes  out  through  the  anterior  condyloid 
foramen.     It  is  entirely  motor,   supplying  the   muscles   of  the 


Fig.   27. — Showing   attitude  in   Spasmodic   Tor- 
ticollis. 


CKANIAL    NEEVES 


135 


tongue,  excepting  the  palatoglossus,  mylo-hyoid,  and  stylo-hyoid. 
The  descendens  noni  branch  communicates  with  the  second  and 
third  cervical  by  the  so-called  communicans  noni  nerve.  Disease 
of  this  nerve  consists  in  paralysis  in  the  majority  of  cases;  irrita- 
tive lesions  seldom,  at 
least,  giving  symptoms. 
The  cause  of  destruction 
of  the  nerve  is  eitlier  cen- 
tral or  peripheral — i.  e., 
is  either  supranuclear, 
nuclear,  or  intranuclear. 
If  central,  it  is  unilateral. 
If  nuclear,  it  miay  occur  as 
a  symptom  in  bulbar  pa- 
ralysis, as  well  as  in  local- 
ized minute  apoplexies. 

Usually  the  cause  of 
palsy  is  neuritis,  specific 
in  origin,  in  which  case 
it  is  apt  to  be  unilateral, 
the  symptomatology  being 
paralysis  of  one  side  of 
the  tongue,  fibrillary  con- 
tractions, and  atrophy. 
The  base  of  the  tongue  is 
elevated   and   the  tongue 

protrudes  towards  the  palsied  side  (Fig.  28).  Diagnosis  of  iso- 
lated lesion  is  made  by  excluding  apoplexy  or  other  paralyses  due 
to  a  very  extensive  central  lesion,  and  in  excluding  neuritis  from 
other  parts  of  the  body.  Atrophy  occurs  in  nuclear  or  intranuclear 
lesions. 

Treatment. — This  depends  entirely  upon  the  cause,  central  le- 
sions and  chronic  specific  disease  usually  causing  permanent  dis- 
ability. Neuritis  from  traumatic  causes  would  be  more  apt  to  be 
relieved  by  antirheumatics  or  by  surgical  interference.  Elec- 
tricity does  not  prove  of  much  avail  in  such  a  limited  area.  The 
use  of  strychnine  is  indicated,  and  tending  towards  regeneration  of 
the  nerve  itself.  Acute  specific  neuritis  is  hopeful  if  full  anti- 
luetic  mixed  treatment  is  earlv  administered. 


X 


Pig.  38. — Supeanuclear  Palsy  of  the  Right 

Hypoglossal  Nerve, 
Showing  tongue  deviation  to  palsied  side  (Phila- 
delphia Hospital). 


CHAPTEE   YII 
'      DISOBDEBS  OF   PERIPHERAL  NERVES 
DISEASES    OF    THE    PERIPHERAL    NERVES 

The  peripheral  nervous  system  consists  of  twelve  pairs  of  cra- 
nial and  thirty-one  pairs  of  spinal  nerves,,  together  with  their  root 
ganglia  and  terminal  sense  and  special  sense  organs;  also  of  the 
sympathetic  nervous  system.  The  sympathetic  system  consists  of 
the  intervertebral  and  the  cranial  ganglia  and  the  peripheral  gan- 
glia. The  latter  arise  during  embryonal  life  from  ganglionic  cells 
of  the  same  class  as  those  of  the  spinal-root  ganglia,  then  later 
migrate  to  their  position  in  the  sympathetic.  According  to  Minot, 
therefore,  the  peripheral  nervous  system  is  composed  of  peripheral 
motor  neurones,  peripheral  sensory  neurones,  and  peripheral  gan- 
glionic neurones. 

Origin  of  Nerves. — Modern  studies  have  shown  that  the  true 
nature  of  the  nerve-fibre  is  but  a  prolongation  of  the  nerve-cell — 
i.  e.,  of  the  axis  cylinder  of  the  cell.  Added  to  this  axis  cylinder 
are  supportive  structures,  also  those  for  insulation  when  the  nerve 
is  complete.  Motor  nerve-fibres,  therefore,  come  from  motor  neu- 
rones and  sensory  nerve-fibres  from  sensory  neurones  or  cells.  All 
peripheral  nerve-fibres  of  motor  nerves  have  in  the  cord  or  brain 
certain  motor  cells  of  origin,  and  these  are  known  as  the  nuclei 
of  origm  of  these  nerves.  This  is  not  exactly  the  same  with  the 
sensory  nerves.  All  sensory  nerve-fibres  take  their  origin  from 
nerve-cells  in  the  posterior  nerve-ganglia,  or  else  in  corresponding 
cranial  ganglia,  such  as  the  Gasserian,  lying  upon  the  cranial 
nerves.  The  nerve-cells  in  these  ganglia  send  off  a  single  process, 
which  divides  in  T-fashion,  the  peripheral  branch  going  out  to 
form  the  sensory  fibre,  the  central  branch  passing  into  the  cord 
or  brain,  and  ending  in  a  terminal  arborization  which  surrounds 
groups  of  sensory  nerve-cells.  Hence,  these  latter  sensory  nerve- 
cells  are  not  nuclei  of  origin,  strictly  speaking,  but  are  terminal 
136 


DISOKDERS    OF    PERIPHERAL    NERVES  137 

nuclei.  Therefore,  there  are  no  nuclei  of  origin  for  sensory  nerves 
in  the  central  nervous  system,  a  matter  of  much  importance  when 
we  come  to  consider  the  anatomy  of  the  cranial  nerves. 

PATHOLOGY    OF    THE    NERVES 

Hypersemia  and  anaemia  of  nerves  brings  about  types  of  nerve- 
irritation  leading  to  various  forms  of  neuralgia,  of  parsesthesia, 
and  of  motor  irritation  or  paresis.  These  conditions  are  usually, 
however,  secondary,  and  are  but  rarely  recognized  clinically,  since 
it  cannot  always  be  determined  whether  an  irritated  nerve  is  anaem- 
ic or  congested  or,  indeed,  whether  the  central  nervous  system 
ma}''  not  be  mainly  at  fault. 

NEURITIS 

This  is  an  inflammation  of  the  nerves.  It  consists  of  inter- 
stitial and  parenchymatous  neuritis.  The  interstitial  neuritis  con- 
sists of  inflammation  of  the  connective-tissue  elements  of  the  nerve 
— the  epineurium  and  endoneurium.  The  parenchymatous  neu- 
ritis consists  of  an  inflammatory  process,  being  located  in  the 
parenchyma.  It  is  further  divided  into  local  and  multiple.  In 
the  local  form  of  the  disease  it  is  frequently  of  the  interstitial 
type,  whereas  in  the  multiple  form  it  is  apt  to  be  of  the  proto- 
plasm of  the  nerve.  It  is  also  divided  into  acute,  subacute,  and 
chronic. 

Symptoms  of  acute  neuritis  are  pain  along  the  course  of  the 
nerve-trunk,  tenderness,  moderate  fever,  and  lessening  of  the  reflex 
in  the  parts  involved,  with  perhaps  hypsesthesia  or  angesthesias,  de- 
pending upon  the  extent  of  the  lesion.  After  the  first  few  days  the 
tenderness  may  largely  subside,  the  sense  of  parsesthesia  lessen,  and 
the  condition  settle  into  a  more  regular  course,  somewhat  below  the 
severity  of  the  onset — i.  e.,  with  lessened  spontaneous  pain  and 
tenderness.  If  localized,  an  active  case-  may  terminate  within  six 
weeks,  or,  if  general  neuritis,  the  acute  may  be  designated  to  those 
cases-  continuing  a  greater  length  of  time.  The  reaction  of  degen- 
eration may  be  found  as  early  as  the  seventh  day  of  the  disease. 

Causes. — Traumatism,  poisons  from  within  and  without,  in- 
fectious diseases,  etc. 

Diagnosis  would  be  only  between  myalgia  and  neuralgia,  in 
which  latter  case  there  is  no  tenderness  on  pressure,  but  rather  an 


138  TEEATISE    ON    NERA^OUS    DISEASES 

alleviatiori  of  the  pain ;  nor  does  elevation  of  temperature^  local  or 
general^  exist  in  neuralgia.  In  myalgia  the  muscle  pain  would 
be  relieved  by  firm  pressure,  while  in  myositis  the  belly  of  the 
muscle  would  be  painful  to  the  grasp,  but  no  nerve-trunk  tender- 
ness would  exist. 

Prognosis  is  guarded  and  depends  upon  general  state  of  health, 
as  well  as  upon  the  severity  and  persistence  of  the  cause. 

Subacute  neuritis  consists  of  the  disease  after  it  has  run  longer 
than  the  average  duration  of  six  weeks,  or  when  the  nature  of  the 
infection  has  been  very  slight  from  the  beginning,  and  consequently 
the  onset  gradual.  In  the  subacute  type  we  have  a  modification 
of  all  the  symptoms;  pain  and  tenderness  are  much  less  severe, 
weakness  of  extremities  and  muscles  less  pronounced,  both  on  ac- 
count of  the  fact  that  the  nerve  structure  is  not  disabled  function- 
ally and  that  there  is  less  pain  at  the  time  of  attempted  muscular 
acts.  Eeaction  of  degeneration  may  be  pronounced.  The  fact 
that  a  case  is  subacute  immediately  makes  the  prognosis  more 
guarded,  since  the  name  itself  implies  a  chronicity  of  the  condi- 
tion or  a  predisposition  to  the  inflammation  of  the  nerves  in  a 
particular  case. 

Diagnosis. — It  is  likely  to  be  mistaken  for  neuralgia,  but  may 
be  confused  with  chronic  rheumatism,  the  difference  between  the 
two  being,  of  course,  the  lack  of  localized  tenderness  along  nerve- 
trunks  in  rheumatic  affections.  If  a  rheumatic  neuritis  exists, 
there  will  also  be  found  other  evidences  of  the  disease  (rheuma- 
tism), such  as  fever,  joint  or  cardiac  involvement,  with  excess  of 
urates  in  the  urine. 

Chronic  neuritis  is  that  form  which  persists  longer  than  three 
months,  and  is,  as  a  rule,  the  sequel  of  the  acute  or  subacute  dis- 
ease. The  symptoms  are  much  more  modified  than  either  of  the 
two  preceding  varieties,  although  localized  atrophy  of  muscles  may 
be  much  more  in  evidence;  also,  reaction  of  degeneration  will 
be  more  distinctly  shown,  while  the  pain  and  tenderness  and  anaes- 
thetic areas  along  the  course  of  the  nerve-trunks  will  be  very  likely 
slight,  but  on  the  other  hand,  from  the  prolonged  disability  and 
muscular  atrophy,  palsy  is  much  more  pronounced,  and  the  re- 
flexes may  be  entirely  abolished,  although  in  some  of  the  chronic 
interstitial  types  of  mild  grade  I  have  even  seen  increase  of  the 
deep  reflexes,  as  the  knee-jerks.  When  the  latter  occurs,  it  can 
be  explained  by  the  irritation  of  the  nerve-fibres  through  inter- 


DISOEDEES    OF    PEEIPHERAL    NEEVES  139 

stitial  connective-tissue  overgrowth^  which  re-enforces  the  reflex 
impulse. 

Diagnosis. — The  ditBculty  lies  between  it  and  chronic  neuritis 
of  rheumatic  type.  Tlie  symptom  pain  may  be  confused  with  the 
pain  of  cord  disease,  as  in  tabes.  In  tabes  we  would  have  other 
evidence  of  spinal-cord  lesion.  There  would  be  no  tenderness  at 
all,  while  anaesthesia  or  other  sensory  changes  would  not  vary 
miich  from  week  to  week  in  cord  lesions  as  it  may  in  neuritis.  As 
between  rheumatism  and  neuritis,  we  have  given  points  above 
which  need  not  be  repeated  here. 

Prognosis. — This  depends  on  the  history  of  alcoholism  or  the 
use  of  other  poisons,  upon  the  vulnerability  of  the  patient,  upon 
the  diathetic  tendency  of  the  individual  towards  rheumatism,  etc., 
and  upon  the  locality  in  which  he  resides,  since  a  low,  damp  coun- 
try would  be  particularly  bad  for  this  malady.  As  a  rule,  patients 
will  recover  if  proper  treatment  can  be  administered  early. 

Treatment. — The  treatment  of  acute  neuritis,  whether  local  or 
multiple,  has  certain  fundamental  principles  to  be  observed.  In 
the  first  place,  rest  of  the  part  involved  as  nearly  absolute  as  possi- 
ble, is  a  desideratum.  The  relief  of  pain  is  due  largely  to  this 
measure  as  well  as  to  cure  of  the  inflammation  itself,  which  is  thus 
favoured  by  absolute  immobility.  A  splint  is  often  a  useful  meas- 
ure for  producing  this  quietude.  If  the  case  is  one  of  multiple  neu- 
ritis, the  patient  should  be  placed  in  bed ;  in  the  acute  form,  and 
in  many  cases  of  subacute  and  chronic  types  cure  will  be  had  much 
more  quickly  if  this  measure  is  adopted  earlier  than  is  at  present 
the  general  practice.  For  relief  of  pain  in  the  acute  form,  local  ap- 
plications of  lead  water  and  laudanum  (25  per  cent)  are  also  of 
value;  the  arm  should  be  protected  by  means  of  cotton  or  heavy 
wool.  Particularly  if  near  a  joint,  the  extremity  should  be  splinted. 
Among  drugs,  the  analgesics  will  do  much  to  control  pain,  such 
as  phenacetine,  antipyrine,  etc.,  in  5-  to  10-grain  doses,  as  re- 
quired. Finally,  hypodermics  of  morphine  may  have  to  be  given 
to  control  this  symptom.  The  use  of  sodium  salicylate  is  com- 
mended, particularly  in  those  cases  of  rheumatic  origin.  Also  the 
employment  of  potassium  iodide  as  an  alterative  is  of  value.  In 
chronic  cases,  with  reaction  of  degeneration,  the  use  of  massage  and 
galvanic  electricity  on  alternate  days  are  valuable  adjuncts  after 
the  acute  pain  and  tenderness  have  subsided.  In  acute  cases  the 
diet  should  be  limited,  but  in  chronic  cases,  where  the  patient  haa 


140  TEEATISE    OX    XEEVOUS    DISEASES 

been  run  down,  the  use  of  nutrients  is  of  par  excellence,  sucli  as 
meats,  regetables,  milk,  etc.,  and  even  cod-liver  oil,  although  in 
cases  of  rheumatic  origin  the  use  of  proteids  should  be  guarded, 
according  to  the  idiosyncrasy  of  the  individual.  The  counter-irri- 
tation over  the  course  of  a  nerve,  by  means  of  blistering,  or  the 
actual  cautery  after  freezing  is  frequently  'of  value.  The  use  of 
strong  tincture  of  iodine  is  another  irritant  I  have  seen  do  good 
service. 

Multiple  neuritis  as  well  as  other  forms  may  be  idiopathic,  or 
its  getiology  may  be  from  sources  already  mentioned  under  the  gen- 
eral head  of  neuritis.  A  better  name  for  the  idiopathic  form  would 
be  essential,  since  this  does  not  imply  that  there  is  not  a  cause, 
even  though  not  discovered.  The  more  frequent  causes,  however, 
are  alcohol  and  lead  and  exposure  or  infectious  diseases,  as  typhoid 
(Fig.  29).  This  type  of  the  disease  pathologically  is  usually  of  the 
parenchymatous  variety. 

Special  Forms  of  Multiple  Neuritis. — In  the  alcoholic  form 
of  multiple  neuritis  there  is  early  toe-drop,  some  pain  along 
the  course  of  the  nerves  of  the  legs  and  arms,  loss  of  knee- 
jerks,  which  may  indeed  be  absent  before  the  patient  complains 
of  weakness  or  pain  in  the  extremities.  There  is  also  consid- 
erable wasting  of  muscles,  with  reaction  of  degeneration  coming 
on  early  in  the  palsy.  The  patient  presents  the  gait  which  is 
styled  the  "  steppage  gait,"  due  to  the  weakness  of  the  anterior 
group  of  muscles  and  sequent  toe-drop.  There  will  also  be  found 
to  be  extreme  gastric  disorder,  as  a  rule;  a  gastric  catarrh,  and 
pains  in  the  abdominal  viscera,  due  to  the  alcohol  irritating  the 
mucous  membrane  of  the  stomach,  with  subsequent  inflammatory 
condition  of.  the  entire  gastro-enteric  mucous  membrane.  There 
may  or  may  not  be  marked  wrist-drop  in  alcoholic  neuritis.  The 
heart  may  be  affected,  the  patient  suffering  from  palpitation  and 
arhythmia,  and  in  some  cases  death  may  result  from  involvement 
of  the  vagi  nerves  or  centres.  Palsy  of  the  extra-ocular  muscles 
may  produce  a  strabismus,  diplopia.  In  some  cases  atrophy  of  the 
optic  nerve  itself ;  and  blindness  may  follow  due  to  the  extension  of 
the  inflammation  of  the  optic  nerves.  The  nails  often  become  brit- 
tle and  transversely  ridged,  caused  by  Inck  of  growth  at  special 
epochs  in  the  course  of  the  malady.  Frequently  the  patient  be- 
comes the  subject  of  a  progressive  muscular  atrophy,  the  result  of 
degeneration  of  the  nerve  protoplasm.     In  alcoholic  neuritis  pain 


DISOEDERS    OF    PEEIPHERAL    NEEVES 


141 


is  not  a  prominent  symptom  (but  it  is  very  pronounced  in  the  so- 
called  idiopathic  cases ) .  The  duration  of  the  disease  may  be  from 
six  months  to  several  years,  the  patient  recovering  at  the  end  of 
this  time  in  the  majority  of  cases  under  proper  treatment. 

In  lead  multiple  neuritis  the  symptoms  are  somewhat  different 
from  those  due  to  alcohol,  inasmuch  as  wrist-drop  is  a  very  distinc- 
tive and  early  symptom,  toe-drop  being  rather  a  secondary  or  late 
phenomenon.  In  lead  neuritis,  the  onset  is  more  rapid,  and  fre- 
quently preceded  by  gastro-intestinal  disturbances,  such  as  tor- 
mina, vomiting,  or  other  evidences  of  lead-poisoning.  Another 
point  is  the  fact  of  the  blue  lines  being  about  the  gums.  This  is 
due  to  reaction  of  the  lead  upon  the  saliva  producing  lead  sulpho- 
cj^anide.  The  blue  line  is  always  at  the  junction  of  the  teeth  and 
gum,  but  is  upon  the  latter.  The  blue  line,  however,  does  not  exist 
when  there  are  no  teeth  present,  it  must  be  remembered,  since  the 


Fig.  29. — Bed-ridden  Case  of  Multiple  Neuritis   (post-typhoid  infection). 
Showing  toe-  and  wrist-drop. 

tartar  is  not  then  present  to  produce  the  characteristic  chemical 
reaction. 

Diphtheritic  Multiple  Neuritis. — Another  variety  of  multiple 
neuritis  fortunate  enough  to  be  given  a  special  place,  and  yet  many 
times  overlooked  by  the  general  practitioner,  is  the  diphtheritic 
form,  which  may  or  may  not  be  associated  with  the  post-diph- 
theritic pharyngeal  parahjsis.  This  I  have  recently  seen  in  the 
case  of  a  doctor  who  had  been  a  most  healthy  specimen  of  man- 
hood, and  who  four  weeks  after  the  onset  of  severe  toxic 
diphtheria  developed  neuritis.    In  him  the  palsy  of  the  throat  was 


142  TEEATISE    OX    NERVOUS    DISEASES 

■very  slight,  but  the  universal  involvement  of  nerves  seemed  to 
show  the  very  profound  intoxication  of  the  nervous  system. 
In  diphtheritic  neuritis,  the  history  of  diphtheria,  or,  if  the  case 
had  not  been  closely  observed,  simply  the  story  of  a  sore  throat, 
will  be  the  deciding  factor,  plus  the  inability  early  to  swallow  well 
or  the  incapacity  to  lift  the  soft  palate  as  in  saying  "  Ah !  " 

Arsenical  neuritis  is  also  a  type  of  multiple  neuritis,  and  is 
frequently  caused  by  prolonged  medication  in  the  use  of  Fowler's 
solution  or  of  arsenious  acid,  either  due  to  the  patient  taking  the 
drug  for  cosmetic  effect,  or  perhaps  in  the  treatment  of  chorea. 

Diagnosis  of  arsenical  poisoning  resulting  in  neuritis  cannot 
be  positively  made  without  a  previous  history  of  poisoning,  since 
there  are  not  sufficient  distinctive  features  to  differentiate  this. 
The  physician  should  always  look  to  the  history  of  the  patient 
sleeping  in  a  room  where  arsenic  has  been  deposited  in  wall  paper 
prepared  by  the  arsenical  process,  not  a  few  cases  having  been 
reported  through  investigations  by  Shattuck,  of  Boston. 

BERI-BERI    OR    KAKKE 

This  is  a  type  of  multiple  neuritis,  particularly  endemic  in  the 
Philippine  Islands.  It  is  probably  infectious.  Some  authors  claim 
it  is  caused  by  CO2  poisoning,  others  that  it  is  due  to  diet  of  fish 
and  rice  containing  fungi.  It  is  associated  with  oedema,  effusion 
into  the  serous  cavities,  such  as  the  pericardium,  the  peritonaeum, 
or  into  the  ventricles  of  the  brain.  It  is  marked  by  paralytic  and 
atrophic  disorders,  anaesthesia,  and  lightning-like  pains.  Death  is 
the  result  of  the  effusions  rather  than  of  the  neuritis  proper,  or 
else  to  early  involvement  of  the  phrenic  or  vagi  nerves.  Mental 
disturbances  are  frecjuent. 

Prognosis. — This  is  absolutely  bad. 

Treatment  of  multiple  neuritis  does  not  differ  in  any  chronic 
type  except  in  so  far  as  separate  causes  are  determined — namely, 
alcohol,  lead,  diphtheria,  or  arsenic.  Treatment  of  the  resulting 
neuritis  would,  at  least,  be  the  same  in  any  case. 

In  the  types  mentioned  there  is  the  possibility  for  aid  through 
early  elimination  of  the  poison.  The  use  of  potassium  iodide  is  a 
valuable  measure  as  an  eliminant  in  all  cases  due  to  poisoning  by 
drugs.  The  source  of  infection  should  he  cut  off.  Besides,  the 
patient  should  take  large  draughts  of  water.  The  persistent  use 
of  general  massage  daily,  fresh  air  and  sunshine,  plus  the  use  of 


DISOPtDERS    OF    PERIPHEEAL    XEEYES  143 

cod-liver  oil  and  hypophosphites,  living  in  a  dry  climate  away, 
from  prevailing  high  winds,  will  insure  success  if  carried  out  over 
many  months  in  cases  where  chronic  invalidism  has  occurred 
from  the  lack  of  persistent  endeavour  in  these  directions  by  either 
the  patient  or  physician.  Strychnine  should  be  given  in  large 
doses  in  cases  of  chronic  neuritis — 3V  to  xo  being  administered 
thrice  daily.  The  use  of  galvanism  is  also  a  valuable  measure 
where  there  is  degeneration  of  nerve  tissue.  In  this  case  the  nega- 
tive pole  should  be  placed  over  the  spine  and  the  positive  over  the 
atrophied  muscles,  a  constant  current  being  applied  to  all  the 
palsied  muscles  for  several  minutes  three  or  four  times  a  week. 
Massage  is  of  great  value  when  administered  daily.  Alcoholic 
cases  must  be  rigidly  guarded  against  indulgence  in  the  drug,  since 
a  small  amount  of  alcohol  will  precipitate  inflammation.  Auto- 
intoxication from  intestinal  fermentation  should  be  prevented  by 
restricted  diet  and  the  use  of  salol  in  moderate  doses  (3  grains 
t.  i.  d.). 

Erythromelalgia  (see  frontispiece)  is  a  variety  of  multiple 
neuritis  affecting  the  dorsal  and  plantar  nerves  of  the  foot.  It  was 
first  described  by  "Weir  Mitchell,  who  gave  it  the  name  of  a  vaso- 
motor neurosis.  We  have  had  the  pleasure  of  studying  two  of 
Mitchell's  cases.  One  was  due  to  a  crush  injury  caused  by  the  fall- 
ing of  a  heavy  stone  upon  the  foot.  The  case  cured  through 
stretching  of  the  plantar  and  by  excision  of  the  cutaneous  nerves. 
The  other  case  died  of  a  complication  of  gangrene  of  the  foot  fol- 
lowing infection  after  the  operation  of  excision  and  stretching  of 
the  internal  saphenous  and  musculo-spinal  nerves,  and  of  stretch- 
ing of  the  posterior  tibial  nerve.  Histological  examination 
showed  neuritis,  thickening  of  the  middle  coat  of  the  vessels  of  the 
amputated  (affected)  foot.  This  obtained  in  the  smallest  arteri- 
oles, while  the  larger  vessels  were  also  calcareous.  This  type  of 
neuritis  has  particular  characteristics.  "When  the  affected  foot  is 
pendant  it  becomes  intensely  red ;  a  severe  burning  pain  is  set  up, 
in  which  the  local  temperature  rises  to  as  much  a&j-°  C.  higher 
than  when  the  foot  is  held  horizontally.  This  is  the  opposite  of 
what  occurs  in  a  normal  extremity,  as  Mitchell  points  out  in  his 
Clinical  Lessons  on  Xervous  Diseases,  pp.  202,  203.  Walking  fre- 
quently is  so  painful  as  to  be  almost  impossible.  Excess  of  perspi- 
ration may  occur  when  the  foot  is  pendant  or  is  paroxysmally  pain- 
ful.   Heat  aggravates  the  pain  also,  while  cold  relieves  it.    Local 


144  TEEATISE    OX    XERVOUS    DISEASES 

ulceration  from  profound  trophic  disturbance  follows  in  bad 
cases. 

Prognosis. — Usually  chronic  and  persistent.  Spontaneous  cures 
have  occurred. 

Treatment  consists  in  rest  in  bed,  local  applications  of  cold, 
protection  of  the  foot  by  cotton  or  splints  loosely  applied.  Galvanic 
electricity,  the  positive  pole  being  placed  over  the  affected  part, 
together  with  etfleurage,  may  afford  relief.  Stretching  and  excision 
of  nerves  are  measures  to  be  adopted  where  relief  fails  from  other 
forms  of  treatment.    The  drug  habit  should  be  guarded  against. 

Recurrent  multiple  neuritis  is  a  type  described  by  Sherwood, 
Ross,  Osier,  and  others.  Certain  individuals  are  susceptible  to  re- 
current attacks  from  definite  poisons,  particularly  from  alcohol 
and  lead.  Since  it  is  not  necessary  for  the  intoxicant  to  be  again 
taken  to  produce  recurrence  of  the  neuritis,  there  must  be  induced 
in  such  patients  a  susceptibility.  Each  recurring  attack  is  likely 
to  be  more  severe  than  the  former. 

Treatment  is  the  same  as  for  other  forms  of  multiple  neuritis. 
It  is  especially  dangerous  for  these  patients  to  be  exposed  to  the 
poison  originally  causing  the  disease. 

Leprous  Neuritis. — The  leprous  bacilli  may  cause  neuritis. 
Proliferation  of  the  nerve-trunks  occurs,  nodules  are  formed,  and 
finally  the  bacilli  may  disappear.  According  to  Martins  and 
Sonza,  the  spinal  cord  may  become  invaded  by  the  bacilli  and 
cavities  form,  especially  in  the  posterior  horns  and  in  the  gray 
commissure.  Sensory  symptoms,  particularly  of  angesthesia,  occur, 
especially  in  large  patches  on  the  face,  hands,  forearms,  feet,  and 
legs.  Through  spreading,  a  very  large  area  may  thus  become 
anaesthetic.  The  small  muscles  of  the  hand  may  be  wasted,  and 
even  the  bones  may  become  atrophic.  There  may  occur  deformi- 
ties of  the  hands  and  feet  due  to  atrophy  of  the  parts,  followed 
by  contractures.  The  toes,  fingers,  hands,  and  feet  may  even  be 
cast  off,  as  in  dry  gangrene.  The  neuritis  may  last  many  years. 
Syringomyelia  of  the  Morvan  type  may  be  simulated  in  some 
cases  through  existent  dissociation  of  cutaneous  sensation,  very 
likely  caused  by  the  disease  in  the  gray  cord  as  noted  above. 

After-treatment  of  Neuritis  (continued). — In  the  toxsemic 
state  following  the  acute  infections,  large  doses  of  iron,  as  of  the 
tincture  of  the  chloride,  are  of  great  value.  If  malaria  is  present, 
quinine  and  arsenic  are  important  remedies.     The  cachexias  that 


DISORDERS    OF    PERIPHERAL    NERA^ES  145 

may  yxist  as  predisposing  causes  should'  be  sought  for  and,  if  pos- 
sible, remedied.  In  cancer,  tuberculosis,  or  in  pernicious  anaemia, 
the  measures  that  cause  general  improvement  will  aid  iii  neuritis. 
In  bad  cases  it  may  be  necessary  to  pass  food  through  the  stomach- 
tube.  If  the  heart  is  at  all  enfeebled,  such  cases  should  be  watched 
most  anxiously  and  quietude  enjoined.  At  times  a  brachial  neu- 
ritis will  thus  end  in  death  suddenly  by  extension  of  the  neuritis 
through  some  anomalous  branch  connected  more  directly  with  the 
vagi  or  phrenic  nerves,  or  else  it  may  be  a  reflex  inhibition  of 
the  heart  that  occiirs. 

Contractures  and  posture  deformities  must  be  very  carefully 
guarded  against,  especially  in  alcoholic  cases.  The  weight  even 
of  the  bed-clothing  must  be  taken  ofE  the  toes  by  means  of  "  hoops  " 
or  other  improvised  apparatus.  At  times  the  use  of  splints,  where 
there  is  not  extreme  sensitiveness,  will  aid  much  in  preventing 
contractures;  as  about  the  ankles.  Passive  movements  in  full  ex- 
tension, and  especially  in  full  flexion  of  the  ankle,  should  be 
used  several  times  a  day  in  the  alcoholic  type.  Heat  applied 
will  at  times  do  good  in  relieving  pain.  We  have  seen  cold  occa- 
sionally do  good,  but  for  some  unknown  reason  it  invariably 
aggravates  any  form  of  neuritis  of  the  upper  extremities,  though 
it  may  do  good,  as  indicated  in  sciatic  neuritis. 

Hot  baths,  Turkish  and  Russian  baths,  or  needle  douches,  as 
advised  by  Charcot,  may  all  be  employed- late  in  the  course  of  the 
disease.  As  with  the  coal-tar  derivatives,  the  use  of  morphine  or 
cocaine  should  be  very  guardedly  emploj^ed.  The  bromides  and 
chloral  combined  allay  cerebral  irritability  and  produce  sleep  more 
safely  than  any  other  drugs.  Static  electricity  is  of  value  to  awaken 
the  circulation  and  aid  metabolism.  This  and  the  faradic  brush 
will  frequently  greatly  benefit  the  cutaneous  anaesthesias.  The  pa- 
tient must  be  encouraged  to  walk  as  soon  as  possible,  since  the 
muscles  gain  power  by  exercise.  Tenotomy  may  be  required  where 
contractions  have  occurred.  The  use  of  deep  kneading  about  in- 
durated joints  caused  by  disuse  and  the  inflammatory  exudate,  is 
of  great  value,  especially  if  associated  with  a  hot  bath  (180°  F.)  in 
an  alkaline  solution  (such  as  of  soap),  the  Turkish  bath,  or  Scotch 
douche. 

SCIATIC   NEURITIS 

This  has  in  the  past  been  confused  with  neuralgia,  or  sciatica, 
but  where  tenderness  is  present  neuritis  must  exist ;  and  as  a  rule. 


146  TREATISE    OX    XEEVOUS    DISEASES 

sciatic  disease  is  neuritic  in  origin.  Sciatic  neuritis  is  a  very 
important  disease  clinicall}^ 

Etiology. — The  canses  are  like  in  other  instances  of  neuritis — 
general  and  local.  It  is  more  frequent  after  twenty-one  years  of 
age.  Gibron  (London  Lancet,  1893)  says  it  is  eight  times  as 
common  in  males  as  in  females,  and  this  is  no  doubt  due  to 
greater  exposure  of  men.  Hence,  exposure  to  cold  and  dampness 
is  one  of  the  most  frequent  causes.  It  is  common  in  puddlers, 
miners,  stokers,  and  cabmen;  neurotic,  rheumatic,  and  gouty  sub- 
jects are  very  liable  to  it.  Lead-poisoning  favours  it.  Diabetes, 
syphilis,  typhoid  fever,  la  grippe,  and  malaria  predispose  to  its 
development.  It  may  follow  operations  for  lithotomy,  childbirth, 
or  from  pelvic  disease  in  women,  or  aneurysmal  pressure.  Bony 
thickening  of  the  sciatic  notch  or  gumma,  in  rare  instances,  are 
causes  of  sciatic  neuritis. 

Lumbago  may  precede  or  complicate  (extension  by  contiguity). 
Compression  of  the  nerve  may  be  a  cause,  as  in  sitting  a  long  time 
on  a  hard  bench,  as  in  shoemakers;  or  it  may  be  a  direct  con- 
tusion of  the  nerve,  as  from  a  blow.  Excessive  fatigue  of  the 
legs  may  precipitate  an  attack,  as  in  prolonged  use  of  the  sewing- 
machine.     The  pressure  of  varicose  veins  may  produce  it. 

Spinal  disease  and  new  -growths  in  the  spinal  canal  may  cause 
sciatic  neuritis  by  first  affecting  the  nerve-roots,  the  vertebral  canal, 
or  at  the  cauda  equina. 

Symptoms. — Pain  and  tenderness  along  the  course  of  the  nerve 
are  the  principal  symptoms.  While  both  of  these  signs  may  ex- 
tend throughout  the  sciatic  distribution,  they  are  more  intense 
in  the  upper  half  of  the  thigh  near  the  sciatic  notch.  The  tender- 
ness is  often  extreme,  and  the  patient  may  be  able  by  this  to  trace 
the  nerve  down  to  the  popliteal  space.  Below  the  knee  the  pain  is 
likely  to  follow  the  external  popliteal.  The  pain  is  more  or  less 
constant,  and  is  very  wearing  upon  the  patient,  especially  since 
exacerbations  occur  mostly  at  night,  keeping  the  patient  awake, 
when  physiological  resistance  of  the  nervous  system  is  lessened. 
Flexing  the  thigh  well  down  upon  the  abdomen,  or  walking,  creates 
added  pain  very  quickly.  Partial  flexion  of  thigh  and  knee,  how- 
ever, with  extension  of  ankle  (a  characteristic  position  when  the 
patient  lies  abed),  will  relieve  pain  through  relaxation.  The  char- 
acteristic gait  of  semiflexion  and  limp  is  due  to  the  same  semi- 
flexion.   If  it  be  a  chronic  case,  lateral  curvature  of  the  spine  may 


DISOEDERS    OF    PEEIPHEEAL    XEEYES  147 

develop,  the  convexity  being  towards  the  affected  side.  This  sco- 
liosis, being  muscular,  disappears  on  recovery.  A  lumbar  con- 
cave curve  and  dorsal  convex  curve  of  the  spine  may  develop  in 
those  rarer  cases,  with  spasm  on  the  affected  side  due  to  neuritic 
extension  to  the  anterior  crural  nerve,  the  sacral  plexus,  or  lumbar 
cord.  This  is  termed  homologous  sciatic  scoliosis,  and  is  likely 
to  become  permanent,  as  the  sciatic  association  symptoms  are 
chronic  and  contractures  develop  which  fix  the  peculiar  deformity. 

Particular  points  of  exquisite  tenderness  in  sciatic  neuritis  are 
designated  tender  points  of  Valleix,  such  as  the  gluteal  point  over 
the  sciatic  notch,  the  trochanteric  point  over  the  great  trochanter, 
the  popliteal  point  at  the  division  of  the  nerve,  and  the  fibular 
point,  where  the  external  popliteal  winds  around  the  head  of  the 
fibula.  There  may  also  be  a  tender  point  on  the  dorsum  of  the 
foot.  In  addition,  in  some  cases  there  may  be  an  iliac  point  about 
the  middle  of  the  crest  of  the  ilium,  lumbar  points  just  above  the 
sacrum,  or  a  patellar  point  over  the  patella;  points  behind  the 
malleoli,  in  the  calf,  or  plantar  points  in  the  sole  of  the  foot. 

It  is  at  these  points  that  the  patient  complains  of  paroxysms 
of  pain  occurring  in  the  course  of  the  disease.  This  pain  may 
be  boring,  burning,  tearing,  or  lancinating  in  character,  which 
tortures  the  patient  to  distraction.  Using  the  limb  or  "  catching 
cold"  will  frequently  at  once  precipitate  an  attack.  At  times 
the  sudden  attacks  of  pain  are  spontaneous  and  periodic,  as  in 
malaria.  Cutaneous  sensibility  is  often  disturbed.  This  may  be 
of  hypersesthesia  in  the  sciatic  distribution  followed  by  anaesthesia, 
or  the  sensitiveness  may  be  confined  to  the  areas  of  the  painful 
points  just  given.  Paresthesias,  such  as  feelings  of  formication, 
fulness,  pricking,  or  of  heat  or  cold,  may  be  present. 

Motor  symptoms,  as  a  rule,  only  appear  in  the  grave  cases. 
Cramps,  violent  tremor  or  spasm  of  calf  muscles  may  be  present 
and  increase  the  pain.  The  Tcnee-jerh  is  rarely  exaggerated;  usu- 
ally it  is  much  diminished,  and  the  heel-jerJc  may  be  absent.  If 
there  is  atrophy  of  muscles  fibrillary  twitching  is  often  found,  and 
there  is  then  palsy  or  paralysis.  In  the  worst  case  a  severe  spasm 
involving  the  entire  limb  may  be  produced,  at  times  creating  the 
most  profound  distress.  A  slight  draught  of  air  or  even  the  sud- 
den touch  of  clothing  may  bring  on  this  spasm,  so  that  the  limb 
must  be  well  protected  from  both.  Vaso-motor  disturbance  may 
cause  flushing  or,  in  severer  cases,  lividity  of  the  limb,  or  even 
10 


148  TREATISE    ON    ^terVOUS    DISEASES 

oedema.  Usually  the  sweat  is  reduced.  It  may  be  increased. 
Erythema^,  acne,  perforating  ulcer  of  foot,  herpetiform  eruptions, 
or  scaliness  may  all  be  found  in  some  cases.  Reaction  of  degen- 
eration may  be  elicited  in  the  wasted  muscles.  In  thin  people  the 
swollen  nerve  may  sometimes  be  easily  palpated.  Excess  of  fat 
may  mask  the  muscular  wasting. 

Double  sciatic  neuritis  is  rare  and  is  usually  the  result  of  pelvic 
or  spinal  disease,  which  makes  the  diagnosis  easy. 

Pathology. — Perineuritis  and  inflammation  of  the  adventitia 
are  present.  The  nerve  parenchyma  suffers  secondarily.  The 
nerve  is  red  and  tumefied  (cedematous).  It  is  therefore  distinctly 
interstitial  neuritis  primarily. 

Diugnosis. — This  must  be  made  from  neuralgia  or  muscular 
rheumatism.  In  the  former  the  pain  is  fleeting,  and  there  is  no 
nerve-trunk  tenderness.  In  muscular  rheumatism  the  pain  is  dif- 
fuse, and  the  muscles  about  are  sore  to  touch.  Hip  disease  is  de- 
termined by  the  joint  tenderness  and  fixation  and  pain  in  the  region 
of  the  obturator  nerve.  Hysteria  may  be  simulated,  but  is  distin- 
guished by  the  fleeting  character  of  the  pain  and  the  emotionalism 
or  other  stigmata.  The  pelvic  organs  and  spine  should  always  be 
looked  to  as  a  possible  source  of  the  inflammation  of  the  nerve.  If 
the  disease  is  bilateral  it  has  pretty  positively  come  from  within 
the  pelvis,  as  from  a  growth,  or  as  indicated  above.  History  of 
syphilis,  malaria,  or  of  exposure,  often  tells  all.  Injection  of  a 
local  anaesthetic  may  stop  pain  for  a  time  when  it  has  begun  or  is 
entirely  located  in  the  nerve,  not  above  the  notch. 

Prognosis. — In  uncomplicated  sciatic  neuritis  the  ultimate  re- 
sult is  good.  If  due  to  spinal  disease,  the  prognosis  is  to  be 
guarded,  since  cure  of  the  original  trouble  is  doubtful.  The  aver- 
age case  will  last  several  months,  but  if  the  part  is  used  the  neu- 
ritis may  last  for  months  or  even  years.  Relapses  are  common. 
If  the  limb  is  wasted  it  may  take  a  year  to  recover  full  use  of  the 
extremity  after  the  pain  has  subsided. 

Treatment  of  Sciatic  Neuritis. — This  is  allied  to  that  of  treat- 
ment of  any  local  neuritis.  Special  measures  consist  of  absolute 
rest  of  the  limb,  the  patient  being  put  to  bed.  Or  a  long,  well- 
padded  splint  can  be  applied  from  axilla  to  external  malleolus,  and 
the  heel  should  be  protected  by  raising  it  from  the  bed  by  a  pad  over 
the  tendo-Achillis,  The  limb  should  be  thus  held  in  a  partially 
flexed  position,  first  having  applied  a  flannel  bandage  from  foot  to 


DISOEDERS    OF    PERIPHERAL    XERA^ES  149 

hip  for  protection  and  warmth.  Diathetic  states,  as  of  rheumatism 
or  gout,  must  be  treated  if  present.  Examination  of  the  urine  is 
very  important  as  to  determination  of  this.  Counter-irritation  by 
means  of  strong  tincture  of  iodine  thrice  repeated,  or  the  use  of 
a  blister,  or  of  the  actual  cautery  of  Paquelin,  are  all  of  great  serv- 
ice. Extremes  of  heat  or  cold  may  do  good  in  individual  cases. 
Thus,  ice-bags  or  hot  poultices  "kept  applied  along  the  course  of  the 
nerve  may  give  great  relief  to  suffering.  I  have  seen  sodium  sal- 
icylate, gr.  X,  every  three  hours  in  peppermint  water,  do  good  in 
acute  cases.  Potassium  iodide  in  chronic  cases  or  injection  of  co- 
caine or  atropine  down  near  the  nerve  may  be  of  much  service. 
But  other  fluids  injected  into  the  tissues  the  writer  has  not  seen 
of  any  service  whatsoever,  nor  has  puncturing  the  nerve-trunk 
been  productive  of  any  relief,  and  there  is  some  danger  of  re-exci- 
ting more  active  inflammation.  Pressure  upon  the  nerve,  as  recom- 
mended by  Negro,  repeating  the  bloodless  procedure  some  six  times 
every  third  day,  may  aid  resolution  in  chronic  cases  with  sheath 
thickening.  Massage  likewise  is  only  valuable  in  chronic  cases. 
Electricity  is  of  most  value  when  used  twice  or  thrice  weekly,  the 
positive  pole  being  applied  over  nerve-trunk  and  calf  (10  to  15 
milliamperes).  Faradization  may  be  of  service  late  in  the  case 
to  develop  atrophied  muscles.  Nerve-stretching  by  the  blood- 
less measure  of  thigh  flexion,  the  knee  being  extended,  or  by 
open  incision  and  lifting  the  limb  from  the  table  by  a  dull  hook 
applied  around  the  nerve-trunk,  are  required  in  stubborn  cases. 
Tumours  near  or  on  an  inflamed  nerve  should  be  excised.  Mor- 
phine hypodermically  may  be  required  in  bad  cases  for  the  pain. 
It  seems  to  produce  a  good  effect  upon  inflammatory  tissue.  Alka- 
line mineral  waters,  as  the  Buffalo  lithia  or  Londonderry  lithia, 
or  a  course  of  alkaline  baths,  as  at  Virginia  Hot  Springs  or  at 
Baden  abroad,  may  be  of  great  value. 

TUMOURS    OF    NERVES 

A.  Hyperplasia. 

B.  True  neuroma;  single  henign. 

C.  False  neuroma;  multiple  henign,  or  malignant. 

A.  Hyperplasia  or  hypertrophy  of  nerve-trunks  is  rare.  It  is 
usually  due,  therefore,  to  increase  of  the  interstitial  connective 
tissue.  At  times  there  is  an  increase  of  fibres  and  thickening  of 
the  myelin  sheath. 


150  TEEATISE    OX    NERVOUS    DISEASES 

B.  True  neuromata  are  also  very  rare,  and  occur  most  exclu- 
sively on  spinal  nerves.  In  some  instances  there  is  an  increase 
in  medullary  fibres,  in  others  only  an  increase  of  non-medullated 
fibres — i.  e.,  only  the  axis  cylinders  and  neurolemma  increase. 
These  tumours  may  occur  single  or  multiple.  Multiple  neurom- 
ata are  generally,  however,  neurofibromata.  ISTerve-fibres  massed 
in  hyperplastic  connective  tissue  form  plexiform  neurofibromata. 

True  neuromata  are  usually  quite  small,  measuring  several 
centimetres  in  diameter  only,  but  they  may  be  much  smaller  or 
larger.  They  are  usually  few  in  number,  though  there  may  be 
a  local  multiplicity  of  these  true  neuromata.  Gowers  has  shown 
that  in  one  case  1,000  were  present,  and  this  number  may  be 
exceeded  in  rare  instances. 

C.  False  Neuromata. — This  term  is  applied  to  nerve  tumours 
intermixed  with  fibroma,  myxoma,  glioma,  sarcoma,  carcinoma,  or 
syphiloma,  although  the  first  is  the  most  common  variety.  Gumma 
has  only  been  found  in  the  false  neuroma  on  the  intracranial  or 
intraspinal  nerves.  Scirrhous  or  medullary  (rarely  the  colloid 
type)  carcinoma  are  the  varieties  found  in  combination.  Leprous 
neuritis  sometimes  forms  neuro-fibromatous  swellings. 

Malignant  Neuromata. — Some  30  cases  of  very  malignant  neu- 
romata have  been  recorded  in  the  literature.  Hereditary  influ- 
ence and  trauma  are  the  setiologic  factors.  The  great  nerve-trunks 
are  most  frequently  affected,  such  as  the  medium  or  sciatic.  The 
tumours  start  from  the  perineurium,  and  are  at  first  spindle- 
shaped  ;  they  may  grow  very  large.  Sarcomatous  cells  are  the  most 
frequent,  but  myxomatous  cells  may  be  found  in  them,  or  fibroma- 
tous  tissue,  or  the  tumours  may  be  mixed. 

Tuhercula  dolorosa  are  simply  false  neuromata  situated  super- 
ficially at  the  ends  of  sensory  nerves. 

.Etiology. — A.  Heredity  generally  tends  to  cause  the  true  mul- 
tiple or  plexiform  neuromata.  B.  Diathetic — e.  g.,  tuberculous — 
influences  which  produce  various  forms  of  tumour  formations — 
sarcoma,  carcinoma,  etc.  C.  Injuries  or  surgical  operations,  which 
cause  especially  the  fibroneuromata,  as  the  amputation  neuroma, 
forming  often  the  so-called  irritable  stump. 

Neuromata  may  be  congenital,  and  are  then  usually  of  the 
plexiform  type.  Multiple  neuromata  may  develop  in  early  life. 
Men  are  more  liable  to  neuromata  than  women. 

Symptoms. — Neuromata  may  not  produce  symptoms,  but  the 


DISORDEES    OF    PEEIPHEEAL    XEEYES  151 

most  frequent  evidences  of  their  presence,  besides  physical  exam- 
ination, are  pain  and  tenderness.  Pressure  above  the  tumour  over 
the  affected  nerve  may  at  times  relieve-  the  exacerbations  of  pain 
probably  by  obtunding  sensation  or  cutting  off  the  blood  supply 
temporarily.  Paresthesia,  anaesthesia,  paralysis,  and  reflex  spasm 
may  be  found.  I  had  a  case  recently  of  false  neuroma  upon  the 
median  nerve  where  spasm  of  the  biceps  muscle  was  most  annoy- 
ing! Some  forms  of  persistent  headache  are  due  to  multiple  neu- 
romata of  the  sensory  fifth.  Single  neuromata  cause  symptoms 
more  frequently  than  multiple  or  plexiform  because  they  are 
points  of  irritation,  as  a  rule,  near  the  periphery  of  the  nerve; 
and  connective  tissue  contracting  in  them  also  aggravates  pain, 
the  multiple  type  being  purely  nerve  tissue.  Keuroma  of  the 
splanchnic  or  vagi  nerve  may  cause  most  serious  symptoms  (sudden 
unaccountable  deaths  are  at  times  due  to  neuroma  of  the  vagus). 

Multiple  (true)  neuromata  may  last  for  years  and  cause  no 
serious  symptoms  or  inconvenience.  Malignant  neuromata  cause 
such  symptoms  as  always  result  from  irritation  or  compression 
of  a  nerve. 

Diagnosis. — The  diagnosis  is  only  positively  made  when  palpa- 
tion reveals  the  tumour.  In  other  cases  diagnosis  is  made  by  ex- 
clusion. Lipoma  over  the  site  of  a  nerve  is  the  most  easily  con- 
founded with  neuroma.  (The  liability  of  lipoma  to  appear  on  any 
part  of  the  body  should  always  make  this  innocent  tumour  thought 
of  in  diagnosis  of  any  growth.)  True  neuromata  are  often  multi- 
ple; the  false  are  usually  single.  .  Idiocy,  lieredity,  neuropatliic 
constitution  would  always  favour  the  disease  being  true  neuroma. 

Treatment  is  essentially  surgical.  Internal  medication  and 
applications  are  valueless  save  as  the  former  is  towards  general 
building  up  of  the  constitution  to  the  invasion  of  disease.  Strong 
galvanic  currents  (descending),  mercury,  and  the  iodides  in  large 
doses  may  assist  in  the  resorption  of  exudate  about  such  a  growth. 
Excision  is  the  proper  treatment  if  pain  or  paralysis  are  prom- 
inent symptoms.     The  growth  may  return. 


CHAPTEE   VIII 

DISEASES  OF  OTHER  SPINAL  NERVES 

A  SINGLE  spinal  nerve  may  be  injured  by  disease  or  trauma, 
or  several  nerves  may  be  injured  by  the  same  local  conditions. 
The  principal  disturbances  resulting  are  those  of  sensations,  or  of 
motor  or  trophic  disorders  which  manifest  themselves  within  the 
distribution  of  the  nerves  involved.     (See  Fig.  8.) 

The  most  usual  lesions  are  new  growths,  division,  degenera- 
tion, neuritis  (see  Chapter  YII).  When  the  lesion  is  irritative, 
the  symptoms  are  of  hypersesthesia,  pain,  spasms,  tremor,  spas- 
ticity, and  rarely  of  hypertrophy.  When  the  lesion  is  destructive 
from  the  first  or  has  passed  on  to  the  destructive  stage,  the  symp- 
toms produced  are  such  as  anaesthesia,  palsy  or  paralysis,  of  dys- 
trophy, atrophy,  or  wasting.  The  above  two  groups  of  symptoms 
are  not  infrequently  blended,  the  result  of  partial  involvement  of 
a  special  nerve  or  of  the  sensory-motor  fibres  being  affected  to  a 
different  degree  in  a  raixed  nerve. 

Cervical  Plexus. — The  phrenic  nerve  arising  from  the  third, 
fourth,  and  fifth  cervical  nerves  may  be  impaired  in  function  by 
penetrating  wounds  of  the  neck,  as  by  a  pistol  shot,  or  by  new 
growths,  or  aneurysm  causing  pressure  upon  it.  Disease  of  the 
cervical  vertebrae,  or  disease  of  the  spinal  meninges,  may  finally 
affect  the  nerve-roots  or  spinal  nuclei.  Inflammation,  primary  or 
secondary,  from  contiguity  with  seats  'of  inflammation,  may  be  a 
cause. 

Sensory  disturbance  in  disease  of  the  phrenic  nerves  may-  simu- 
late the  pain  of  intercostal  neuralgia  or  of  rheumatism;  but  its 
association  with  the  motor  symptom.s  will  clear  this  up.  The  latter 
will  consist  of  inactivity  of  the  diaphragm,  unilateral  or  bilateral, 
as  shown  by  failure  of  the  abdominal  walls  to  advance  with  deep 
inspiration.  If  the  lesion  is  of  both  phrenic  nerves  the  breathing 
is  distinctly  of  feminine  or  costal  type;  the  dyspnoea  is  extreme. 

The  suprascapular  nerve,  which  arises  from  the  fourth,  fifth, 
and  sixth  cervical  nerves,  may  be  affected  singly  in  dislocations  of 
153 


DISEASES    OF    OTHER    SPINAL    NERVES         153 

the  shoulder.  If  so,  the  supraspinati  and  infraspinati  muscles  be- 
come atrophied,  the  scapula  being  prominent.  Also,  the  external 
rotation  of  the  arm  is  impeded,  with  general  weakness  of  the  mem- 
ber due  to  lack  of  balance  at  its  fulcrum,  the  shoulder- joint.  Wri- 
ting is  very  difficult  for  the  reason  given.  There  may  be  an  ances- 
thetic  area  over  the  outer  aspect  of  the  scapula  and  posterior  por- 
tion of  the  deltoid  region. 

The  long  or  posterior  thoracic  nerve,  branching  from  the  fifth 
and  sixth  cervical  nerves  and  supplying  the  serratus  muscle, is  quite 
frequently  exposed  to  mechanical  pressure,  as  from  heavy  weights 
carried  upon  the  shoulder  by  expressmen,  etc. ;  or  it  may  be  com- 
pressed by  muscular  efforts  exerted  by  overhead  workers,  as  plas- 
terers, etc.;  or  by  swinging  the  arm  constantly,  as  in  chopping, 
mowing,  or  tailoring.  For  all  these  reasons  men  in  active  early 
life  are  more  frequently  affected,  and  usually  on  the  right  side, 
because  the  majority  are  "  right-handed."  The  nerve  may  also  be 
affected  along  with  others  in  the  course  of  spinal  disease. 

Symptoms  are  mostly  motor,  since  it  is  almost  a  pure  motor 
nerve.  These  consist  of  impairment  of  expansion  of  the  chest  on 
the  side  affected,  and  of  diminished  movement  of  the  upper  ex- 
tremity, as  a  result  of  the  non-fixation  of  the  scapula.  The  in- 
trinsic muscles  of  the  arm  itself  are  not  weakened.  The  deformity 
from  paralysis  of  the  serratus  produces  a  peculiarly  characteristic 
disfigurement.  Placing  the  arm  forward  causes  the  posterior  bor- 
der of  the  scapula  to  widely  wing  out  from  the  chest,  so  that  a 
deep  recess  is  formed  behind  the  shoulder-blade.  The  upper  por- 
tion of  the  scapula  also  moves  outward,  and  the  lower  angle  ap- 
proaches the  spine.  Sensory  phenomena  are  but  slight,  and  con- 
sist of  pain  in  the  neck  and  shoulder  in 'case  neuritis  coexists. 

Prognosis  is  less  favourable  than  in  injury  to  other  spinal 
nerves,  even  though  the  disease  affecting  it  is  a  simple  pressure 
neuritis.  This  may  be  due  to  the  fact  that  pressure  is  usually 
made  along  a  much  greater  extent  than  in  the  case  of  any  other 
nerves  that  may  be  so  injured. 

The  treatment  of  palsy  of  the  phrenic  nerve  will  be  entirely 
confined  to  treating  the  cause,  since  the  nerve  is  inaccessible  to 
mechanical  stimulation,  and  this  is  largely  so  with  palsy  of  the 
suprascapular  or  the  long  thoracic;  but  galvanism  can  be  em- 
ployed to  advantage  in  some  cases  by  placing  the  negative  pole  over 
the  digastric  region  and  the  positive  down  the  border  of  the  scap- 


154  TEEATISE    OX    XERVOUS    DISEASES 

ula  on  the  affected  side.     Strj-chnine;,  gr.  gV  to  yV  three  times  a 
day,  may  prove  of  value.    Massage  is  of  most  service. 

CERVICO-OCCIPITAL    NEURALGIA 

The  symptoms  of  neuralgia  of  the  first  four  cervical  nerves, 
especially  of  the  occipital  branch,  are  caused  by  exposure  to 
draughts,  catching  cold,  rheumatism,  etc.  Pain  here  may  also  be 
due  to  caries  of  the  cervical  vertebrae.  It  may  be  associated  with 
neuralgia  of  the  fifth  nerve  and  with  torticollis.  The  pain  is 
usually  located  in  the  occipital  and  at  times  in  the  posterior  pari- 
etal region.  It  may  be  bilateral.  There  may  exist  tenderness  of 
the  scalp.  Tender  spots  are  found  (a)  in  the  triangle  between 
the  trapezius  and  sterno-cleido-mastoid  muscles;  (&)  at  the  angle 
of  the  great  occipital  between  the  mastoid  process  and  the  spine; 
(c)  above  the,  parietal  eminence. 

Prognosis  is  usually  good  excepting  where  the  disease  comes 
on  late  in  life. 

Treatment  consists  in  counter-irritation  to  the  neck  and  occi- 
put by  means  of  strong  tincture  of  iodine,  the  fly-blister,  or  the 
actual  cautery.  Galvanism  with  the  positive  pole  of  a  galvanic 
current  placed  over  the  three  tender  points  indicated  above  is 
of  value.  A  hypodermic  injection  of  morphine,  gr.  ^  to  gr.  -J, 
guarded  by  atropine,  gr.  i^q,  may  be  required  during  an  exacerba- 
tion of  pain.  Quinine  in  full  doses  or  sodium  salicylate  pushed 
to  the  physiological  limit  are  of  value.  Arsenious  acid  is  a  de- 
sirable alterative  in  these  cases,  especially  where  aneemia  compli- 
cates, when  Blaud's  pill,  gr.  v,  t.  i.  d.,  should  be  added. 

The  Circumflex  Nerve. — This  nerve  arises  from  the  fifth,  sixth, 
and  seventh  cervical  nerves,  and  descends  in  the  posterior  cord  of 
the  brachial  plexus.  It  then  branches  off,  to  pass  outward  under 
the  deltoid  muscle,  and  winding  around  the  neck  of  the  humerus  is 
distributed  to  the  teres  minor  and  deltoid  muscles,  also  supplying 
the  shoulder-joint  with  trophic  influence.  It  also  supplies  sensa- 
tion to  a  chevran-shaped  area  over  the  lower  two  thirds  of  the 
deltoid.  From  its  exposed  position  it  is  often  injured  in  shoulder 
dislocations,  in  arthritis,  or  by  falls  or  blows  upon  the  shoulder; 
or  by  crutch  pressure. 

Symptoms  of  paralysis  of  the  circumflex  nerve  consist  of  in- 
ability to  abduct  the  arm  from  the  body  due  to  deltoid  paralysis. 


DISEASES    OF    OTHEK    SPIXAL    NEEYES         155 

while  the  palsy  of  the  teres  minor  is  insignificant.  Soon  the  del- 
toid wastes  and  the  shoulder  becomes  pointed  and  prominent,  with 
the  shonlder-joint  relaxed  from  sequent  dragging  upon  its  liga- 
ments. The  head  of  the  humerus  can  be  felt  very  readily.  Nutri- 
tion of  the  joint  failing,  it  becomes  the  seat  of  neuro-arthritis  and 
partial  ankylosis.  This  is  ascertained  by  noting  synchronous 
movement  of  the  scapula  with  arm  motion.  An  initial  arthritis 
may  likewise  spread  by  continuity  to  the  circumflex  nerve  and 
injure  the  deltoid.  AnjBsthesia  over  the  skin  distribution  of  the 
deltoid,  already  described,  is  usually  present  in  circumflex  paral- 
ysis. 

Prognosis  is  guardedly  favourable  in  cases  not  due  to  frac- 
ture. 

Treatment  consists  of  blistering,  sodium  salicylate  in  rheumatic 
cases,  and  after  the  tenth  day  galvanism,  massage,  and  move- 
ments, kept  up  for  months. 

Paralysis  of  the  infrascapular  nerve,  which  arises  from  the 
fifth  and  sixth  cervical  roots,  consists  of  palsy  of  the  supraspina- 
tus  and  infraspinatus  muscles,  which  it  supplies;  but  isolated 
paralysis  of  these  muscles  is  rare,  palsy  of  this  nerve  usually  being 
associated  with  deltoid  palsy  from  circumflex-nerve  disease  due  to 
dislocation  of  shoulder-joint,  etc.  Paralysis  of  these  two  muscles 
alone,  however,  causes  loss  of  power  of  outward  rotation  of  the 
humerus,  shown  in  loss  of  power  of  carrying  the  hand  from  left  to 
right,  as  in  writing. 

Prognosis  is  also  guarded,  since  it  is  difficult  to  determine  the 
extent  of  injury. 

Treatment  is  exactly  similar  to  that  of  circumflex  palsy,  save 
that  massage  and  electricity  are  applied  directly  over  the  muscles 
involved;  so  that  treatment  is  more  available  at  least. 

The  musculo-spiral  nerve  arises  from  the  posterior  brachial 
cord,  and  winds  around  the  humerus  in  the  musculo-spiral  groove 
between  the  two  heads  of  the  triceps  muscle,  where  it  can  be  sub- 
jected to  muscular  pressure,  external  violence,  or  pressure.  It  is 
the  most  frequently  diseased  nerve  in  the  body,  and  at  the  same 
time  is  the  one  in  which  disease  is  best  in  its  prognosis. 

This  nerve  supplies  all  the  extensors  of  the  elbow,  wrist,  and 
fingers;  also  both  supinators,  and  through  its  radial  branch  the 
skin  on  the  dorsal  surface  of  the  thumb  and  two  radial  fingers, 
and  the  posterior  radial  border  of  the  hand.     It  furnishes  as  well 


156  TREATISE    OX    XEEVOUS    DISEASES 

trophic- joint  filaments  to  the  carpus  and  hand.  High  up  it  also 
supplies  cutaneous  branches  to  the  skin  in  an  area  extending  from 
the  wrist  in  a  narrow  but  widening  strip  up  the  forearm,  and  over 
the  outer  aspect  of  the  arm  as  high  as  the  insertion  of  the  deltoid 
muscle.  These  latter  branches  are  but  seldom  involved  in  palsy 
of  the  circumflex. 

Causes  of  disease  of  the  circumflex  nerve  are  legion.  It  may 
be  due  to  lead-poisoning,  when  the  posterior  interosseous  branch 
( "  nerve  of  lead  palsy  " )  is  most  affected,  wrist-drop  being  the 
only  prominent  symptom  in  such  cases.  In  pals)'  of  the  circum- 
flex from  drug-poisoning,  it  is  also  interesting  to  note  that  the 
supinator  longus  is  not  affected.  From  its  exposed  position  in 
the  axilla  crutch  pressure  frequently  causes  pressure  palsy;  or  it 
may  here  be  due  to  dislocation  of  the  head  of  the  humerus.  Lower 
down  the  nerve  is  liable  to  suffer  from  blows  upon  it,  by  being 
caught  in  callus  or  fractures,  or  by  a  cord  being  tied  about  the  arm, 
or  even  by  direct  action  of  the  triceps  catching  the  nerve  in  its 
grasp,  as  in  extreme  muscular  exertion.  By  far  the  most  common 
cause  is  from  pressure  by  the  patient  lying  on  his  arm,  or  when 
it  hangs  over  a  chair,  he  being  asleep,  in  alcoholic  poisoning.  The 
reason  for  this  is  that  the  alcohol  benumbs  sensibility  and  the  pa- 
tient is  not  awakened  by  the  parEesthesia  that  would  occur  under 
normal  circumstances.  Of  course,  such  pressure  may  occur  under 
any  form  of  narcotism.  The  surgeon  must  be  careful  not  to  have 
'pressure  upon  this  nerve,  in  operations,  while  the  patient  is  anaes- 
thetized. Hanging  pendant  when  under  an  ansesthetic  may  also 
produce  pressure  palsy  from  the  ijuU  made  on  the  nerve.  Finally, 
"  catching  cold "  may  be  the  cause  of  neuritis  and  palsy  of  the 
circumflex. 

Symptoms. — Sensory  symptoms  are  slight  and  at  times  not 
present  when  the  motor  fibres, of  the  nerve  are  almost  completely 
functionless.  If  present,  it  would  be  in  the  course  of  the  radial 
and  cutaneous  branches  of  the  musculo-spiral.      (See  Fig.  32.) 

Motor  symptoms  are  widespread  and  characteristic.  There  is 
wrist-drop  and  inability  of  all  the  long  extensors  of  the  hand  to 
react  if  the  lesion  is  high  up.  There  is  also  inability  to  extend 
the  elbow.  If  the  nerve  is  affected  in  the  musculo-spiral  groove, 
the  most  usual  location  as  stated,  the  branches  to  the  triceps 
escape  and  extension  of  the  elbow  is  not  lost.  Lesions  below  the 
lower  one  third  of  the  humerus  do  not  catch  the  branch  to  the 


DISEASES    OF    OTHEE    SPIRAL    NERVES         157 

supinator  longus.  The  position  of  the  hand  (Fig.  30)  is  char- 
acteristic. The  fingers  can  only  be  extended  by  the  interossei 
muscles,  after  the  first  phalanges  are  extended,  which  latter  are 
supplied  by  the  ulnar  nerve.  The  thumb  cannot  be  extended  and 
the  fingers  can  be  but  a  very  little  better,  being  progressively  dimin- 
ished from  the  index  to  the  little  finger.  Occasionally,  on  the 
back  of  the  wrist  there  develops  a  synovial  tumour  due  to  extreme 
carpal  flexion,  and  in  part  due  to  insufficient  support  of  the  ex- 
tensor tendons,  also  to  involvement  of  the  articular  branches  of 
the  nerve.  This  tumour  is  painless  and  much  exaggerates  the 
wrist  deformity.  The  "  grasp  "  is  greatly  reduced,  due  to  the  ex- 
tensor loss  and  unbalancing  of  the  muscle  movements.  Muscular 
wasting  shows  on  the  dorsal  surface  of  the  forearm,  and  where 
the  supinator  longus  is  involved  a  peculiar  flattening  of  the  fore- 
arm is  noticed.    The  triceps  may  be  somewhat  wasted. 

Prognosis  is  good  in  the  vast  majority  of  cases,  cure  resulting. 


Fig.  30.— Wrist-Drop  from  Musculo-spiral  Alcoholic  Pressure  Palsy. 

Treatment  consists  in  getting  rid  of  the  cause,  as  of  alcohol, 
callus,  crutch  pressure,  etc.,  or  of  suturing  of  the  nerve  if  it  has 
been  severed.  Ordinarily  the  use  of  a  blister  over  the  supposed  site 
of  lesion  is  indicated.  The  arm  can  be  placed  in  a  well-padded 
anterior  splint  where  there  is  marked  wrist-drop.  -This  will  tend 
to  prevent  joint  deformity  in  chronic  cases.  Massage  and  fara- 
dism  after  the  fifth  day  are  indicated  in  compression  cases  with 
separation  of  the  nerve  elements.  Strychnine  in  full  doses  is  the 
drug  indicated  par  excellence.  In  eases  of  active  neuritis  the  case 
is  to  be  treated  more  conservatively  as  one  of  local  inflammation. 

The  ulnar  nerve,  originating  from  the  lowest  cervical  and  first 
dorsal  nerves,  and  supplying  the  forearm  and  ulnar  flexor  of  the 
wrist,  the  two  inner  divisions  of  the  deep  flexor  of  the  fingers 
and  all  the  small  muscles  of  the  hand  except  those  innervated  by 


158  TEEATISE    OX    XEEVOUS    DISEASES 

the  median,  the  abductor  of  the  thumb,  and  one  half  of  the  short 
flexor  of  the  thumb,  also  supplying  sensation  to  the  ulnar  border 
of  the  hand,  including  the  little  finger  and  half  the  ring  finger, 
is  when  palsied  likel}'  to  give  a  wide  distribution  of  symptoms. 

Causes. — Neuritis,  idiopathic  or  from  trauma,  tumours,  pres- 
sure or  separation  as  by  a  knife  or  crockery  cut.  It  may  be  in- 
jured (a)  above  the  elbow,  (&)  at  the  elbow,  or  (c)  at  the  wrist. 

Symptoms. — Sensory  symptoms  consist  of  loss  of  sensation  in 
one  half  of  ring  and  all  of  little  finger,  running  up  the  palm  and 
back  of  hand  to  wrist,  where  it  tapers  off. 

Motor  symptoms  are  marked.  The  wrist  cannot  be  actively 
flexed  to  the  ulnar  side,  and  the  thumb  is  rotated  towards  the  palm 
by  the  abductor,  and  cannot  be  adducted.  The  fingers  lose  lateral 
motion.  There  is  overextension  of  the  metacarpophalangeal  joints, 
while  the  unopposed  flexors  of  the  second  and  third  are  offset  by 
strong  contraction  of  these  digits  towards  the  palm,  making  the 
so-called  "  claw  hand.'^  This  flexion  is  least  marked  in  the  index 
and  middle  fingers,  which  do  not  lose  their  lumbrical  muscles.  The 
interosseous  spaces  are  hollowed  and  the  fifth  metacarpal  bone  is 
entirely  subcutaneous.  The  hypothenar  eminence  disappears,  but 
part  of  the  thenar  eminence  stands  out  prominently. 

Prognosis  is  good  if  the  palsy  is  due  to  separation  as  by  a  knife- 
cut  and  nerve-suturing  is  done  at  once.  In  cases  of  fracture  of  the 
ulna,  with  compression,  good  results  will  only  follow  early  eradica- 
tion of  the  offending  bone  or  callus.  Idiopathic  cases  of  neuritis 
are  less  promising  of  cure. 

Treatment  consists  first  in  getting  rid  of  the  cause  if  surgery 
will  do  it,  as  indicated  under  prognosis.  Acute  neuritis  should 
be  combated  along  ordinary  lines.  Massage  and  galvanism  are 
the  most  valuable  adjuncts  to  the  medical  treatment,  consisting 
of  strychnine,  the  iodides,  and  general  tonic  measures.  (It  is  of 
interest  here  to  note  the  sudden  restoration  of  function,  especially 
of  sensation,  in  case  of  suturing  of  the  nerve  after  section,  thus 
giving  a  clue  to  the  possibility  of  nerve  force  being  through  some 
such  agent  as  electricity.) 

Median  Nerve. — This  nerve  arises  from  the  inner  and  outer 
cords  of  the  brachial  plexus,  and  follows  the  brachial  artery  to 
the  bend  of  the  elbow.  It  supplies  all  the  flexors  except  the  ulnaris, 
and  the  ulnar  portioii  of  the  deep  flexor.  It  also  supplies  both 
pronators.     In  the  hand  it  supplies  the  opponens,  abductor,  the 


160  TREATISE    ON    NERVOUS    DISEASES 

short  flexor  of  the  thumb,  and  the  first  and  second  lumbricals. 
These  latter,  like  the  interossei,  are  accessory  to  flexors  of  the 
fingers  (first  joints),  and  are  aids  to  common  extensors  for  ex- 
tension of  the  second  and  third  phalanges.  The  sensory  distri- 
bution of  the  nerve  supplies  the  radial  half  of  the  hand  on  the 
palmar  side,  and  the  tips  of  the  index  and  middle  fingers  on  the 
dorsal  aspect.     (See  Figs.  31  and  32.) 

Cause  of  Paralysis. — Injury  in  common  with  the  ulnar  and 
musculo-spiral  near  the  axilla  may  be  the  cause  of  paralysis.  Stab 
wounds  near  the  wrist  are  not  uncommon  sources  of  palsy,  also 
sprains  about  the  wrist,  or  fractures,  as  Colles's. 

Symptoms,  Sensory. — These  are  usually  slight,  due  to  the  ex- 
tensive distribution  of  the  ulnar  and  radial  nerves  about  the  same 
areas,  but  would,  in  complete  loss  of  function,  be  in  the  distribu- 
tion already  given.  Motor:  Pronation  is  destroyed.  The  thumb 
cannot  be  rolled  into  the  hand  or  opposed  to  the  fingers.  None  of 
the  fingers  can  be  fiexed  except  the  ring  and  little  fingers,  which 
still  act  through  the  ulnar  portion  of  the  flexor  profundus  and 
interossei.  The  wrist  is  flexed  slightly  to  the  ulnar  side  through 
the  flexor  ulnaris.  The  first  joints  of  the  fingers  are  still  able  to 
be  slightly  flexed  through  the  interossei.  The  hand  becomes  flat- 
tened because  the  thenar  eminence  is  atrophied  and  the  thumb  lies 
in  adduction  parallel  to  the  other  fingers  ("ape  hand").  It  is 
the  same  deformity  seen  in  progressive  muscular  atrophy  of  spinal 
origin. 

Prognosis  is  guardedly  favourable  if  the  disease  has  not  gone 
more  than  six  weeks  without  proper  treatment. 

Treatment  consists  in  thorough  massage,  the  use  of  the  ascend- 
ing galvanic  current,  10  milliamperes  daily  five  minutes;  strych- 
nine, gr.  -gV  t.  i.  d.,  and  local  protection  (splinting)  and  alter- 
atives, as  sodium  iodide  and  arsenic.  Nerve  suture  even  late  as 
six  months  after  nerve  severance  has  been  attended  with  good 
results. 

COMBINED    PALSIES    OF    NERVES    OF    THE    ARM 

The  proximity  of  the  brachial  plexus  to  bony  prominences  of 
clavicle,  scapula,  and  humerus  makes  it  liable  to  injury  as  a  whole ; 
hence,  palsy  of  its  various  nerve  branches  may  result.  The  mus- 
culo-cutaneous,  suprascapular,  and  circumflex  may  also  be  af- 
fected secondarily  to  disease  of  the  fifth  and  sixth  cervical  nerves. 


DISEASES    OF    OTHER    SPINAL    NERVES         161 

from  which  they  arise.  Peterson  quotes  from  the  Revue  Neurolo- 
gie,  December  15,  1900,  that  forcible  dragging  of  the  arm  up  or 
down  may  lacerate  the  anterior  nerve-roots. 

Or  a  neoplasm  or  injury  opposite  the  sixth  cervical  vertebra 
may  affect  both  nerves.  At  this  point  (between  the  scaleni  mus- 
cles) Erb  has  found  that  the  circumflex  and  suprascapular  nerves 
can  be  stimulated  by  electricity.  The  muscles  involved  in  such 
a  palsy  are  the  spinati,  deltoid  biceps,  and  brachialis  anticus,  while 
the  sensory  disturbance  corresponds  to  the  cutaneous  distribution 
of  the  nerves  affected. 

Injuries  to  the  brachial  plexus  are  usually  severe.  I  have  never 
seen  a  crush  involving  the  branches  recover.  As  a  rule,  injuries 
involve  all  its  branches.  But  single  nerves — e.  g.,  the  ulnar — may 
be  affected ;  or  the  ulnar  in  association  with  the  nerve  of  Wrisberg, 
etc.,  in  which- case  anaesthesia  along  the  entire  inner  aspect  of  the 
arm  will  also  accompany  the  motor  palsy.  The  so-called  "  birth 
palsies  "  are  due  to  traction  on  the  arm,  or  to  the  use  of  a  hook  in 
the  axilla  or  to  head  forceps  during  delivery;  and  usually  involve 
all  the  branches — viz.,  the  median,  ulnar,  and  musculo-spiral.  A 
fracture  of  the  humerus  may  injure  the  musculo-spiral  and  ulnar 
nerves.  The  radial  and  ulnar  nerves  may  be  simultaneously  in- 
jured in  fractures  in  the  forearm  or  disease  at  the  wrist.  In- 
fected wounds  of  the  hand  may  produce  ascending  neuritis,  which 
may  ultimately  affect  the  entire  brachial  plexus  (neuritis  mi- 
grans). 

Pott's  or  other  disease  of  the  vertebrae  may  affect  the  brachial 
nerves  secondarily,  as  also  may  meningitis,  particularly  the  hyper- 
trophic form:  or  even  disease  of  the  cord,  as  syringomyelia,  may 
do  the  same  thing. 

Prognosis  has  been  indicated. 

Treatment  will  consist  of  getting  rid  of  the  cause  at  once  if 
degeneration  and  an  ill  result  shall  not  follow.  The  other  measures 
to  be  adopted  will  be  described  below. 

Brachial  Neuritis. — Gowers  compares  this  with  sciatic  neuritis. 
The  symptoms  consist  of  pain  and  tenderness  in  the  distribution 
of  the  branches,  particularly  when  the  shoulder  is  moved,  since 
the  circumflex  is  then  much  disturbed  as  well  as  the  other  nerves, 
though  to  a  less  degree.  The  pain  is  often  mistaken  for  neuralgia, 
for  rheumatism  of  the  shoulder  or  arm;  careful  examination  will 
eliminate  these.     Women  suffer  more  frequently  than  men.     The 


162 


TREATISE    OX    NERYOrS    DISEASES 


disease  occurs  oftener  after  middle  life,  especially  in  gouty  or 
rheumatic  people.  Lumbago  or  sciatica  may  also  be  existent  in 
the  case.     I  have  seen  a  needle  prick  in  the  finger  in  two  cases 


External  Cutaneous 
Genito-Crural 


Anterior  Crura] 


External.Popliteal 


■  Uio-Inguinal 


-  Long  Saphenous 


Fig.   -34. — Showing  the  Distribution  of  the  Sensory  Nerves  of  the  Skih, 
Anterior  Aspect  of  Trunk  and  Leg. 


produce  most  profound  brachial  neuritis.  The  entire  arm  becomes 
wasted  and  the  hand  flattened.  The  muscles  as  well  as  the  nerves 
are  tender,  and  the  slightest  movement  gives  severe  shooting  pain 
in  the  arm  and  neck.     Reaction  of  degeneration  is  found.     The 


DISEASES    OF    OTHER    SPIXAL    XERVES         163 

reflexes  are  iisiuilly  diminished^  but  as  in  chronic  sciatica  may 
rarely  be  exaggerated. 

The  prognosis  is  most  serious  as  to  cure,  relapses  being  com- 
mon in  the  most  favourable  cases. 

Treatment  consists  in  rest  of  mind  and  body  as  fundamental 
principles.  The  lithsemic  state  must  be  looked  to.  Counter- 
irritation  along  the  course  of  the  plexns  and  nerves  by  the  actual 
cautery  affords  great  relief.  Dry  heat  will  often  do  good.  Cold 
usually  aggravates.  Protection  of  the  arm  by  a  splint  or  cotton 
wool  is  a  valuable  remedial  measure.  Ascending  galvanism  is 
of  value.  Amputation  of  the  arm  below  the  insertion  of  the  del- 
toid is  the  only  treatment  for  severe  laceration  of  the  brachial 
plexus.  In  this  way  the  incumbrance  of  a  totally  palsied  arm  is 
done  away  with,  to  the  comfort  of  the  patient. 

NERVES    OF    THE    TRUNK 

These  nerves  supplied  by  the  thoracic  and  two  upper  pairs  of 
lumbar  nerves  are  rarely  singly  involved.  Pott's  disease  may 
affect  them,  but  the  loss  is  slight  unless  several  nerves  are  affected 
simultaneously.  The  girdle  sense  of  tabes  or  neuritic  pain  of 
vertebral  disease  are  diagnosticated  by  observing  other  signs  of  the 
respective  diseases.  Herpes  zoster  may  encircle  the  body,  and  in 
such  cases  the  symptomatic  disorder  is  significant  of  serious  root 
mischief  either  due  to  extension  from  spond5ditis  or  to  sclerotic 
involvement,  as  in  tabes ;  or  it  may  be  from  direct  metastasis  from 
a  neoplasm.  Unilateral  herpes  is  rather  characteristic  of  gastro- 
intestinal disorder  only.  Wide-spread  trunkal  herpes  is,  as  a  rule, 
due  to  final  disease  of  the  gray  matter  rather  than  of  the  nerves 
themselves.     (See  Figs.  34:  and  35  for  cutaneous  nerves  of  trunk.) 

NERVES  OF  THE  LOWER  EXTREMITY 

These  are  not  so  frequently  involved  as  those  of  the  arm,  but 
are  subject  to  special  disease  through  pressure  in  pelvic  growths,  and 
in  females  by  pressure  upon  the  sacral  plexus  during  labour.  In- 
flammation of  pelvic  viscera  or  psoas  abscess  may  affect  the  plexus. 
(See  Figs.  33  and  3i  for  cutaneous  nerves  of  lower  extremities.) 

The  external  cutaneous  branch  of  the  anterior  crural  nerve 
supplying  the  outer  side  of  the  thigh  is  very  liable  to  disease.  A 
queer  condition  termed  parcBsthetic  meralgia,  consisting  of  a  sense 
11 


164 


TREATISE    ON    NERVOUS    DISEASES 


of  burning  (causalgia)  in  the  outer  upper  aspect  of  the  thigh,  is 
found  in  neurasthenic  women,  especially  when  secondary  to  ovarian 
disease ;  probably  caused  by  a  reflex  reference  through  irritation  of 
this  sensory  branch.    In  other  cases  a  neuritis  has  been  set  up. 


Fio.  35. — Showing  the  Distribution  of  the  Sensory  Nerves  of  the  Skin. 
Posterior  Aspect  of  Trunk  (Butler). 

Gout,  rheumatism,  excesses  in  tea-drinking,  in  alcohol  or  to- 
bacco may  cause  it,  or  as  a  resultant  of  multiple  neuritis  this 
peculiar  hypersesthesia  may  continue  for  months  or  years. 

Treatment  consists  in  treating  the  neurasthenia  and  in  nerve- 
stretching,  which  usually  is  successful. 

Anterior  Crural. — This  nerve  may  be  affected  (a)  within  the 
abdomen,  when  flexion  of  the  thigh  on  the  abdomen  is  weakened 
because  the  iliacus  muscle  is  included,  and  (&)  below  Poupart's 
ligament. 


DISEASES    OP    OTHEE    SPINAL    NERVES         165 

Symptoms  due  to  cutting  off  of  entire  function,  are  wasting  of 
the  quadriceps  and  abolition  of  the  knee-jerk.  Anwstliesia  will  be 
found  to  extend  from  the  groin  to  the  inner  side  of  the  foot.  There 
is  but  a  narrow  strip  of  normal  sensation  remaining,  which  runs 
down  the  back  of  the  thigh  below  the  knee,  spreads  oiit  over  the 
external  portion  of  the  calf,  embracing  the  foot  except  on  the  inner 
aspect.     (See  Pigs.  33,  34,  and  36.) 

'Prognosis  is  good  if  the  cause  can  be  eradicated.  When  due 
to  pelvic  tumour,  it  is  hopeless;  but  disease  of  the  internal  geni- 
talia, if  causative,  being  eradicated  will  relieve  the  secondary  neu- 
ritis. Idiopathic  cases  must  be  treated  as  neuritis  elsewhere.  Ap- 
plying a  long  external  splint  is  of  great  service.  Galvanism  and 
massage  are  valuable  after  acute  symptoms  have  abated. 

Obturator  Nerve. — This  nerve  comes  from  the  same  source  as 
the  anterior  crural  nerve.  It  supplies  the  adductors  of  the  thigh, 
also  the  knee  and  hip-joints.  Hence  it  is  that  "  referred  "  pain  may 
be  to  the  knee  in  cases  of  coxalgia  or  disease  of  the  knee  may  be 
referred  to  the  hip  of  same  side. 

Causes. — Prolonged  horseback-riding  may  cause  the  neuritis,  or 
tearing  of  the  muscles  by  athletes;  or  a  direct  trauma  may  pro- 
duce neuritis  of  the  obturator. 

Symptoms  of  paralysis  of  this  nerve.  Proper  adduction  of  the 
thighs  is  prevented;  there  is  impaired  external  rotation  of  the 
thigh  through  palsy  of  the  external  obturator  and  pectineus  mus- 
cles. Wasting  occurs  on  the  inner  aspect  of  the  thigh  above.  Sen- 
sory symptoms  consist  of  knee  or  hip  pain,  depending  upon  whether 
one  or  both  branches  are  involved. 

Treatment  consists  of  rest,  massage,  galvanism,  and  relief  of 
pain  by  anodynes  or  by  hot  applications  of  lead  water  and 
laudanum,  twenty-five  per  cent.  Disease  of  knee  or  hip  should  be 
treated. 

The  superior  gluteal  nerve  may  be  inflamed,  and  this  causes 
palsy  of  the  gluteus  minimus  and  medius  and  the  tensor  vagina 
femoris  muscles.  The  symptoms  consist  of  weakness  of  abduc- 
tion, outward  rotation,  and  circumduction  of  the  thigh. 

The  Great  Sciatic  Nerve. — The  size  and  exposure  of  this  nerve 
and  its  branches  make  it  more  liable  to  disease  than  any  other 
single  nerve  of  the  lower  extremity.  It  supplies  the  knee  flexors, 
which  are  also  partial  extensors  of  the  thigh  upon  the  body.  It 
also  applies  all  muscles  below  the  knee.    (See  Pigs.  33,  34,  and  35.) 


166  TREATISE    OX    XEEYOUS    DISEASES 

Symptoms.- — From  the  peculiar  mechanical  position  of  the  mus- 
cles palsied  in  disease  of  this  nerve,  the  disability  to  the  patient 
is  less  than  that  resulting  from  disease  of  the  anterior  crural 
nerve  above  recited.  The  paresis  of  muscles  supplying  onlv  ahoiit 
the  large  joints  of  the  hip  and  knee  is  the  explanation  of  this. 
The  leg  is  carried  forward  iti  progression  as  a  "  pegleg  "  similar 
to  that  of  the  hemiplegic  gait.  Wasting  is  marked.  Perforating 
ulcer  of  foot  may  follow.  Sensory  phenomena  consist  of  anaes- 
thesia occupying  the  narrow  strip  of  the  thigh  posteriorly  and  the 
outer  aspect  of  leg  and  foot  described  in  the  last  section. 

Disease  of  the  external  popliteal  or  peroneal  nerve  may  be  lo- 
cated (a)  in  the  ham  or  (&)  below  the  knee  on  the  outside  of 
neck  of  the  femur.  This  branch  nerve  supplies  the  long  extensors 
of  the  toes,  also  the  peronei  muscles. 

Symptoms,  Motor. — Foot-drop  with  toe-drop  follow;  and 
equinovarus  may  result  from  contraction  of  the  ttnopposed  flex- 
ors. There  is  much  wasting  about  the  fibula  and  in  the  anterior 
group  of  leg  muscles.      (See  also  Sciatic  Xeuritis.) 

The  internal  popliteal  nerve  supplies  the  calf  muscles,  the  long 
flexors  of  the  toes,  all  the  small  mtiscles  of  the  foot  save  the  short 
extensors  of  the  toes.  If  its  branch,  the  internal  plantar,  is  di- 
vided, there  results  a  paralj^sis  of  the  short  flexor  muscles  of  the 
toes,  the  plantar  muscles  of  the  great  toe,  except  the  adductor, 
and  the  two  inner  lumbricales.  "  Hammer-toe  "  results  from  ex- 
tension of  first  joint  and  flexion  of  second  joint.  Sensory  symp- 
toms consist  of  auEesthesia  in  the  outer  plantar  surface  of  half  the 
sole,  one  half  of  the  fourth,  and  all  of  the  fifth  toe.     (Fig.  36.) 

If  the  external  plantar  branch  is  alone  involved,  the  symptoms 
are  loss  of  power  of  the  muscles  of  the  little  toes,  the  two  outer 
lumbricales,  all  the  interossei,  and  the  adductor  of  the  great  toe. 
The  hammer-toe  deformity  is  found  in  all  the  toes.  Sensory  symp- 
toms then  consist  of  anaesthesia  in  the  outer  plantar  surface  of 
half  the  sole,  one  half  of  the  fourth,  and  all  of  the  fifth  toe. 

If  the  internal  popliteal  is  divided  in  the  popliteal  space  in 
addition  to  above  symptoms,  there  is  inability  to  rotate  the  flexed 
leg,  due  to  palsy  of  the  popliteus  muscle ;  and  also  a  loss  of  power 
of  extending  the  foot.  Talipes  calcaneus  may  therefore  result 
with,  in  addition,  the  arch  of  the  foot  becoming  exaggerated. 

Morton's  Disease,  or  Metatarsalgia. — I  have  seen  a  number  of 
cases  under  the  discoverer's  care.     Dr.  Morton  considered  it  due 


Long  saphenous 


Anterior 
tibial 


Internal    External 
plantar      plantar 


External  plantar 
(Br.  post,  tibial) 


Internal  plantar 
(Br.  post,  tibial) 


Anterior 
tibial 


Long, 
saphenous 


Internal  plantar 


External  saphenous 


External  plantar 


Long  saphenous 


Muscu  lo-euta  neoue 
(Br.  ext.  popliteal) 


Posterior  tibial 
Anterior  tibial 


Internal  plantar 


Fia  36.— Showing  the  Distkibution  of  the  Sensory  Nerves  of  the  Skin  of 

THE  Foot  (Butler). 

167 


168  TEEATISE    0^    NEEVOUS    DISEASES 

to  pressure  neuritis  of  a  filament  of  a  digital  branch  of  the  exter- 
nal plantar  nerve  lying  between  the  heads  of  the  metatarsal  bones. 
Narrow  shoes  may  favour  its  development,  as  may  gout. 

The  symptoms  consist  of  sudden  excruciating  pain  in  or  near 
dorsum  of  foot  opposite  the  fourth  toe.  This  pain  shoots  up  the 
leg,  and  may  be  relieved  by  firm  pressure,  as  of  a  lace  shoe;  or  by 
placing  in  the  boot  a  "  sole  plate  "  as  manufactured  by  Gefvert. 

Prognosis  in  gouty  cases  is,  however,  bad.  Excision  of  the  head 
of  the  fourth  metacarpal  bone  is  the  radical  measure  that  we  have 
seen  effect  a  cure  in  several  cases. 

Treatment  of  palsies  of  the  various  branches  of  the  sciatic  nerve 
outlined  above  consists  in  nerve  suture  for  division;  of  getting 
rid  of  adjacent  local  disease,  as  tumours,  fracture,  or  callus;  and 
in  the  treating  of  any  diathetic  tendencies.  Other  treatment  useful 
is  described  under  Sciatic  ISTeuritis. 

RHIZOMELIQUE  SPONDYLITIS 

This  disease  consists  of  an  osteo-arthritis  of  the  spine  of  un- 
known origin ;  hence  it  can  be  set  down  as  probably  dependent 
u]3on  trophic  disturbance  through  the  nervous  system.  Deformity 
ma3^  result,  depending  upon  whether  the  interarticular  vertebral 
fibro-cartilages  are  absorbed  or  not  before  the  proliferation  and 
ossification  occurs  about  the  respective  joints.  When  the  disks  are 
absorbed  quickly,  kyphosis,  scoliosis,  and  other  deformities  of  the 
spine  follow.  The  large  joints  near  the  body  are  next  attacked, 
such  as  the  hip,  knees,  and  shoulders.  The  Eoentgen  rays  show 
bony  exuclate  and  the  absorption  of  cartilages  as  described. 

etiology  is  not  definite.  Heredity,  cold,  wet,  and  trauma  or 
gonorrhceal  infection  are  all  supposed  to  be  factors  in  individual 
cases.  But  the  above  causes  may  be  but  exciting  elements,  the  dis- 
turbed metabolism  from  lowered  nutrition  being  the  predisposing 
cause. 

Symptoms. — These  are  entirely  dependent  as  to  the  nervous 
system  upon  trophic  disturbance  noted  (also  atrophy  of  muscles 
may  occur  as  in  two  cases  that  are  under  the  writer's  care  at  the 
Philadelphia  Hospital  at  the  present  time)  or  upon  whether  spinal 
nerves  or  spinal  cord  are  encroached  upon  by  pressure,  etc.  Pain 
and  limitation  of  motion  are  usually  prominent  symptoms.  The 
pain  may  be  severe  and  be  "  referred,"  or  occur  at  the  site  of  the 
spine  disease,  usually  then  at  anterior  aspect  in  the  back  of  abdo- 


Fig.  37.— Rhizomblique  Spondylitis  (Doksal,  Spine). 
(Medico-Chixurgical  Hospital.) 


169 


170  TREATISE    OX    NERVOUS    DISEASES 

men.  It  is  worse  after  sleeping,  f)robably  due  to  sluggish  circula- 
tion during  sleep  producing  stagnation  of  circulation  about  a  dis- 
eased area;  also  to  metabolites  irritating  the  sensory  nerve  roots. 
"  Girdle  pains "  are  one-sided  usually,  because  one  side  of  the 
vertebral  column  is  first  attacked.  There  is  impairment  of  mo- 
tion in  the  legs;  or,  indeed,  complete  paraplegia  may  result.  Close 
study  may  reveal  areas  of  hypereesthesia,  hypsesthesia,  or  anaes- 
thesia depending  on  the  lesion  being  at  the  time  an  irritative  or 
destructive  one.  Coughing  or  movement  of  the  head  or  trunk  will 
bring  on  severe  pain.  According  as  the  erosion  of  cartilage  and 
osseous  deposit  predominates  or  muscular  spasm  is  productive 
of  the  rigidity  or  deformity,  will  they  be  of  more  or  less  permanent 
nature. 

Prognosis. — Ultimately  the  patient  may  become  entirely  bed- 
ridden and  helpless  save  for  the  use  of  the  smaller  joints.  Occa- 
sionally the  disease  is  stayed  from  advance  by  timely  hygiene  and 
treatment. 

Treatment  consists  of  constitutional  and  hygienic  measures. 
Sirup  hypophos.  comp.,  oi  t.  i.  d.,  or  cod-liver  oil  in  cold  weather 
are  valuable  nutritional  drugs.  Sod.  salicylat.,  gr.  s  t.  i.  d.,  or 
potassium  iodide,  gr.  x  t.  i.  d.,  or  syr.  ferri,  iodidi,  a  half  drachm 
after  meals,  are  respectively  the  best  antirheumatics,  alternatives, 
and  hsematics  that  can  be  employed.  Look  to  the  kidneys  and  the 
eliminative  functions  generally.  A  toxic  process  in  the  intestine 
may  aggravate,  hence  the  use  of  salol,  gr.  ii,  in  elix.  lactopeptine, 
a  drachm,  thrice  daily,  may  be  desirable.  The  digestive  tract 
must  also  be  conserved  in  these  patients  and  full  simple  diet  given, 
including  abundance  of  eggs  and  milk.  The  orthopedic  surgeon 
may  aid  by  bloodless  operation  of  extension  or  through  applying 
apparatus,  or  by  use  of  a  wheel  crutch  to  get  the  patient  about 
on  his  feet.  I  have  had  one  case  thus  bettered,  so  that  from  being 
bedridden  he  could  walk  about.  His  general  health  was  much 
improved. 


CHAPTER   IX 
INFLAMMATION  OF  MENINGES 

DISEASES    OF    THE    MEMBRANES    OF    THE    BRAIN 

We  shall  consider  here  anemia,  hyperfemia,  inflammation  of 
the  dura  mater  (pachymeningitis),  and  inflammation  of  the  pia 
mater  (leptomeningitis). 

Ancemia  of  the  membranes  of  the  brain  cannot  be  well  sepa- 
rated from  anfemia  of  the  encephalon  itself,  and  must  therefore 
be  studied  with  ansemia  of  the  brain. 

Eypercemm  must  likewise  be  considered  with  hypersemia  of  the 
brain  so  far  as  that  of  the  pia  is  considered.  Dural  congestion 
or  hyperasmia  may  occur  as  the  result  of  injuries,  of  sunstroke,  of 
poisons  such  as  uric  acid,  or  of  infectious  diseases,  such  as  mea- 
sles, scarlet  fever,  and  syphilis;  the  symptoms  bein^  like  those  of 
pachymeningitis  of  the  congestive  stage,  which  will  be  described 
under  that  heading.  The  principal  symptoms,  are,  however,  ver- 
tiginous attacks  and  peculiar  sensations  of  fulness  in  the  head. 
The  treatment  is  the  same  as  for  the  onset  of  meningitis. 

INFLAMMATION    OF   THE    DURA    OR    PACHYMEN- 
INGITIS   EXTERNA 

Since  the  so-called  pachymeningitis  interna  is  probably  a  hgem- 
orrhagic  disease  (or  hsematoma  of  the  dura  mater),  it  will  be  de- 
scribed under  the  head  of  dural  haemorrhage.  It  is  extremely 
rare  to  have  a  true"  simple  internal  meningitis  of  the  dura.  (See  p. 
175.) 

Pachymeningitis  externa  first  involves  the  outer  surface  of  the 
dura.    There  are  less  pressure  symptoms  than  in  hsematoma. 

MENINGITIS 

This  implies  inflammation  of  the  membranes  of  the  cord  and 
brain,  being  divided  iiito  jjachymeningitis  (dura)  and  leptomen- 
ingitis  (pia),  each  in  turn  being  divided  into  acute  and  chronic 

171 


172  TEEATISE    ON    NERVOUS    DISEASES 

simple  meningitis;  and  secondarily  into  acute  and  chronic  infec- 
tions meningitis,  the  latter  including  infectious  cerebro-spinal 
meningitiS;,  tubercular,  leptotlirix  infection,  and  tlie  various  strep- 
tococci infectious  forms.  Various  other  organisms  produce  in- 
flammation of  the  membranes,  the  principal  ones,  however,  being 
included  in  the  above  list.  Usually  when  we  speak  of  meningitis 
we  refer  to  meningitis  of  the  dura,  so  that  specifications  should 
be  made  of  these  inflammations  for  the  sake  of  exactness. 

ACUTE   CEREBRAL   PACHYMENINGITIS 

Inflammations  of  the  Membranes  of  the  Brain. — This  may  be 
primary  or  secondary,  the  former  being  caused  by  the  so-called 
"  catching  cold,"  or  exposure  to  cold,  or  exposure  to  extreme  heat. 
The  causes  of  the  latter  form  are  infectious  diseases,  such  as 
pneumonia,  typhoid  fever,  infectious  cerebro-spinal  meningitis, 
injuries,  carious  bone  as  from  mastoid  disease,  syphilis,  erysip- 
elas, etc. 

Symptoms. — This  disease  is  usually  ushered  in  by  a  marked 
chill,  followed  by,  as  a  rule,  hyperpyrexia,  the  temperature  run- 
ning up  to  104°  or  106°  F.  The  patient  may  suddenly  pass  into 
convulsions  of  tonic  and  clonic  nature,  with  retraction  of  the 
head,  delirium,  mania,  and  hyperemesis,  frequently  of  the  projec- 
tile type.  The  convulsions  may  be  localized  or  at  least  begin  in 
one  member,  due  to  irritation  of  a  jDarticular  centre  over  the  motor 
cortex.  Paralysis  may  follow.  The  pupils  usually  are  irregularly 
dilated.  There  may  be  amblyopia,  due  to  optic  neuritis,  which  is 
soon  set  up  in  severe  eases  and  accompanied  by  marked  swelling 
of  the  disks.  Various  other  palsies  may  occur,  producing  internal 
strabismus  or  external  strabismus,  frequently  accompanied  by 
diplopia.  It  is  very  rare  that  hemianopsia  follows.  Hearing  may 
be  affected  in  the  beginning,  it  being  acute  as  is  the  case  with 
the  other  special  senses.  Late  in  the  disease  deafness  or  dul- 
ness  of  hearing  may  occur.  Localized  facial  palsies  may  also 
follow  ^spasm  of  these  muscles,,  due  to  the  involvement  of  the 
nuclei  of  the  facial  nerves.  If  the  basilar  membranes  are  involved 
bulbar  symptoms  may  supervene;  or  a  deafness,  or  blindness  in 
the  most  serious  cases.  The  duration  of  acute  pachymeningitis  will 
depend  upon  the  degree  of  infection  or  the  resisting  power  of  the 
patient.     Death  may  follow  early  severe  convulsions.     The  acute 


INFLAMMATION    OF   MENINGES  173 

symptoms  may  last  a  week  or  ten  days,  when  termination  by  crisis 
may  occiir.^  Or,  as  is  the  rule,  a  gradual  defervescence  of  the 
fever  and  recovery  with  more  or  less  sequelae,  depending  upon  the 
severity  of  the  disease. 

Prognosis. — In  children  it  is  worse  than  in  adults,  owing  to  the 
lack  of  resistance  through  immature  development  of  the  nervous 
system  in  them.  Occasionally  a  case  will  recover  with  apparently 
absolute  integrity  of  the  nervous  system  and  no  sequelge  whatever, 
but  in  the  vast  majority  of  cases  some  defect  is  left  behind,  either 
blindness,  due  to  progressive  atrophy  of  the  optic  nerves,  or  deaf- 
ness from  involvement  of  the  acoustic  nerves,  etc.  These  two  spe- 
cial senses  are  the  most  frequently  involved,  although  the  others, 
but  very  rarely,  may  also  be  affected.  Sequelae,  as  hemiplegia, 
paraplegia,  or  monoplegia  of  spastic  type,  depending  upon  the  de- 
gree of  involvement  of  the  motor  cortex,  are  frequent. 

Treatment. — This  will  depend  entirely  upon  the  nature  of  the 
cause.  If  primary  disease  or  any  septic  foci  exist  in  the  body,  these 
should  be  dealt  with  at  once.  (The  treatment  of  infectious  cere- 
brospinal meningitis  will  be  considered  in  its  proper  place.) 

The  patient  should  be,  as  a  rule,  placed  in  a  dark  room,  in  quiet 
surroundings,  and  well  protected  from  atmospheric  exposure. 
Such  measures  are  necessitated  by  the  extreme  hyperexcitability  in 
the  beginning  of  the  disease.  Hyperpyrexia  should  be  treated 
by  antipyretics  guardedly  administered,  by  the  sponge-bath  or  ice- 
pack, and  in  some  cases  of  plethoric  individuals  venesection  should 
be  tried.  The  application  of  leeches  to  the  temple  or  wet  cups  to 
the  nape  of  the  neck  are  valuable  methods  of  depleting  the  con- 
gested meninges;  to-day  not  enough  used.  For  the  control  of  con- 
vulsions, the  antipyretic  measures  detailed  may  be  sufficient  in  the 
milder  cases,  but  in  the  more  serious  ones  the  use  of  large  doses 
of  bromides  and  chloral  may  be  necessary.  If  these  cannot  be 
retained  by  the  stomach  they  should  be  given  per  rectum,  and  in 
twice  the  dosage  as  given  by  the  mouth.  If  heart  failure  occurs 
later  in  the  course  of  the  disease,  cardiac  stimulants  may  be 
necessary,  such  as  digitalis,  or  in  acute  syncope  hypodermics  of 
ether  or  strychnine  may  be  necessary,  continued  until  the  crisis 
is  past.    In  case  of  injury  or  abscess,  surgical  help  must  be  sought. 

*  Kernig's  sign  may  be  present  in  meningitis — viz.,  the  inability  to  extend 
the  legs  while  sitting,  but  ability  to  do  so  wben  recumbent.  It  is  ?iot  pathog- 
nomonic of  the  disease. 


174  TEEATISE    OX    XERVOUS    DISEASES 

Potassium  or  sodium  iodide  are  valuable  remedies  for  the  absorp- 
tion of  the  exudate.  If  betterment  of  ocular  troubles  does  not 
occur  with  this,  the  destruction  of  the  cranial  nerves  passing  out 
at  the  base  of  the  brain  may  be  inferred  and  a  basilar  type 
confirmed.  The  treatment  of  sequelse,  as  optic  atrophy,  etc.,  will 
be  the  province  of  specialists  in  this  department  of  medicine,  to 
whom  the  case  should  be  early  referred.  Epilepsy  may  be  a  sequel, 
and  should  be  treated  symptomatically  if  the  original  source  of 
irritation  cannot  be  removed. 

Causes  of  Clironic  Meningitis. — This  is  generally  the  result  of 
the  acute  form.  Some  cases  are  so  insidious  that  they  are  desig- 
nated subacute  or  chronic  from  the  first  discovery  of  symptoms. 
Sunstroke  is  quite  frequently  a  cause  of  this  type,  as  may  be  lues 
or  trauma. 

Symptoms. — Persistent  headache  of  a  dull  character,  worse 
when  the  patient  is  exposed  to  heat  or  when  he  stoops  forward 
or  lies  down.  He  also  complains  of  pain  in  the  neck,  frequently 
radiating  towards  the  shoulders,  and  may  suffer  from  general 
paresis  of  the  extremities,  usually  of  a  spastic  nature.  Or  he  may 
be  the  subject  of  deafness,  vertigo,  or  optic  atrophy.  Such  pa- 
tients, too,  may  be  subjects  of  secondary  epilepsy. 

Diagnosis. — This  is  to  be  made  from  chronic  cerebritis,  tumour 
of  the  brain,  hydrocephalus.  In  cerebritis  there  is  usually  more 
mental  failure  or  even  dementia  with  less  spasticity  of  any  existent 
palsy.  In  tumour  of  the  brain  the  special  predominance  of  optic 
neuritis  (95  per  cent),  together  with  localizing  symptoms,  will 
difi!er"entiate,  while  in  hydrocephalus,  the  enlargement  of  the  head 
of  the  peculiar  metallic  sound  on  percussion,  or  the  exophthalmos, 
are  points  for  differential  diagnosis. 

Prognosis. — This  is  usually  bad  as  to  permanent  recovery,  the 
patient  being  liable  to  exacerbations  at  any  time,  due  to  catching 
cold  or  exposure  to  heat.  In  adults  the  chronic  form  of  menin- 
gitis may  exist  for  many  years.  In  children,  since  interference 
of  development  of  the  brain  follows,  life  is  materially  curtailed 
even  in  the  milder  cases,  such  patients  usually  succumbing  early  to 
intercurrent  disease.  Blindness  and  deafness  occur  in  the.  chronic 
form  as  the  result  of  the  acute  type,  and  as  a  rule  such  cases  are 
practically  incurable.    Imbecility  is  not  unusual. 

Treatment. — This  will  simply  consist  of  additional  measures 
to  those  already  referred  to — namely,  the  treatment  of  the  convul- 


INFLAMMATION    OF    MENINGES  175 

sions  or  of  contractures  and  of  palsies,  which  latter  may  require  the 
services  of  the  orthopsedic  surgeon.  Massage  and  Swedish  move- 
ments should  be  given  a  fair  trial  in  these  cases.  If  a  large  exu- 
date, especially  of  the  hgemorrhagic  type,  or  a  localized  blood  tumour 
of  the  dura  exists,  the  surgeon  may  by  prompt  operation  save  the 
patient's  life,  as  I  have  known  in  one  case.  Extensive  counter- 
irritation  over  the  scalp  is  of  value. 

CEREBRAL    PACHYMENINGITIS    INTERNA    HJEMOR- 
RHAGICA  OR   HyEMATOMA    DURA 

This  is  a  type  of  local  inflammation  involving  the  internal 
layer  of  the  dura.  It  is  more  frequent  in  male  adults  and  in  those 
subject  to  chronic  alcoholism  or  prolonged  intoxication. 

Symptoms  are  insidious,  the  patient  complaining  of  pain  in  the 
head,  following  an  alcoholic  debauch.  There  are  manifest  symp- 
toms of  dementia,  such  as  loss  of  memory,  incoherent  speech,  with 
periods  of  excitement.  Frequently  the  patient  will  pass  into  an 
urgemic  state,  which  is  due  no  doubt  to  kidney  insufficiency  at  the 
time,  even  though  the  kidneys  may  not  be  permanently  disabled. 
The  case  may  recover  from  the  ursemic  attack  rather  suddenly. 
Usually  within  a  few  days  or  a  week  recurrence  of  symptoms  oc- 
curs, such  as  added  weakness  of  the  extremities,  more  pronounced 
upon  one  side  of  the  body.  Fifty  per  cent  of  the  haemorrhages  are 
on  one  side  of  the  dura.  The  mental  obtundity  'deepens,  the  pa- 
tient passes  into  delirium.  There  is  also  noticed  general  tremu- 
lousness.  It  will  be  found,  too,  that  the  paralysis  is  much  more 
spastic  than  the  rapidity  of  onset  and  the  extent  of  motor  weak- 
ness would  warrant.  This  is  a  point  of  value  in  making  the  diag- 
nosis of  this  serious  malady.  A  distinct  point  in  the  symptomatol- 
ogy is,  therefore,  exacerbations  and  remissions  without  profound 
coma  at  any  time  until  late  in  the  disease. 

Diagnosis. — This  disease  is  so  difficult  to  diagnose  that  it  seems 
useless  to  set  down  differential  points.  Ingravescent  htemorrhage 
into  the  cerebrum  may  be  mistaken  for  it,  as  well  as  uraemia,  indi- 
cated above.  From  the  former  it  may  be  distinguished  by  the 
more  exact  symptomatology  of  true  apoplexy  in  the  latter.  From 
uraemia,  the  urinary  examination  would  be  of  great  value,  since 
the  lesser  bulk  of  albumin,  if  any,  would  be  found  in  a  meningitis. 

Progfiosis. — This  is  absolutely  bad.    The  patient  is  usually  car- 


176 


TEEATISE    OX    XEEVOUS    DISEASES 


ried  off  "within  ten  days  after  the  onset  of  symptoms.  Death  gen- 
erally occurs  not  alone  perhaps  from  the  haemorrhage,  which  is 
usually  massive  and  spread  over  the  entire  cortex  of  one  side,  but 
very  likely  it  is  completed  by  the  general  alcoholic  toxaemia  existent 
in  these  patients. 

Treatment. — This  consists,  therefore,  in  the  same  form  as  the 
acute  meningitis  given  above.     Surgical  ireatmejit  is  not  as  yet 


Pig.    .38.— H.emorkhagic     Pachtmenixgitis    Ixterxa    (Alcoholic).      Specimen 
from  a  case  in  the  Philadelphia  Hospital.     (Dura  is  reversed  in  the  photograph.) 


fully  developed,  and  has  not  been  resorted  to  in  many  cases,  but 
would  seem  to  be  the  onlv  possible  chance  of  saving  the  patient's 
life.  If  it  were  not  for  the  extreme  asthenia,  a  diagnosis  could 
be  made  and  the  surgeon's  skill  in  trephining  and  removing  the 
clot  might  save  some  cases.  Yenesection  arid  transfusion  of  nor- 
mal salt  solution  is  a  treatment  that  should  be  resorted  to  in 


IXFLAMMATIOX    OF    MENINGES  177 

cases  of  marked  toxgemia.     Supportive  measures  should,  of  course, 
be  insisted  upon  in  all  these  cases. 

CEREBRAL    LEPTOMENINGITIS 

This  is  usually  an  acute  infection.  It  is^  as  a  rule,  secondary 
to  some  septic  foci,  as  abscess  of  the  lung,  liver,  etc. 

.  Symptoms. — These  are  fulminating  in  character,  accompanied 
by  high  temperature,  great  mental  anxiety,  and  a  hectic  type  of 
temperature  curve,  which  remains,  at  about  104°  or  106°  F.  Con- 
vulsions are  not  so  common,  nor  -spactic  rigidity  of  muscles  so 
frequent  as  in  the  acute  form  of  pachymeningitis,  nor  is  intense 
head  pain  of  so  great  importance  as  in  the  former  disease.  Local- 
ized palsies  of  sudden  development  are  rather  frequent,  depending 
upon  exudation  over  a  motor  centre.  Duration  of  the  disease  is 
from  a  few  days  to  ten  days,  the  patient  usually  succumbing  with 
the  hyperpyrexia  or  from  the  general  infection.  Termination  by 
crisis  may  occur,  or  a  chronic  septic  inflammation  of  the  brain 
may  result. 

Prognosis. — This  is  bad  in  the  majority  of  cases.  Death  of 
the  patient  usually  takes  place  within  seventy-two  hours.  In  many 
cases  a  remote  abscess  in  the  brain  may  be  the  result  of  the  above 
disease. 

Treatment. — This  would  not  be  different  from  that  for  pachy- 
meningitis excepting  that  it  is  more  incumbent  to  seek  for  septic 
foci  both  in  the  brain  and  in  other  organs,  to  which  it  is  so  fre- 
quently secondary. 

HYDROCEPHALUS 

This  is  a  condition,  congenital  or  acquired,  in  which  there 
is  an  accumulation  of  the  fluid  within  the  ventricles  of  the  brain. 
There  are  two  types  of  hydrocephalus,  external  and  internal.  It  is 
again  divided  into  acute  and  cJironic,  although  the  chronic  form  is 
the  more  common  variety.  The  internal  type  implies  an  excess- 
ive collection  of  fluid  within  the  ventricles,  whereas  the  external 
type  refers  to  cases  in  which  the  fluid  is  mainlv  in  the  subdural 
space.  Usually  the  two  are  coexistent,  but  internal  hydrocephalus 
always  predominates. 

Symptoms  of  acute  liydroceplialus  may  follow  acute  inflam- 
mation of  the  epend}Tna.     It  is  more  usual  in  babyhood  and  in 


178  TEEATISE    OX    XERVOUS    DISEASES 

children  suffering  with  marasmus,  in  which  subjects  there  seems  to 
be  a  special  tendency  to  local  inflammation  of  this  serous  lining  of 
the  brain.  Symptoms  are  those  of  subacute  meningitis,  excepting 
that  convulsions  are  not  so  frequent  and  the  temperature  is  never 
so  high  as  in  the  former  disease.  The  child  is  usually  in  a  condi- 
tion of  muscular  rigidity,  however,  the  attack  itself  generally  being 
induced  by  autointoxication.  In  addition  to  the  muscular  rigidity 
with  tetanic  spasmus,  at  times  there  is  evident  an  enlargement  of  the 
head,  bulging  of  the  fontanelles,  and  depression  of  the  eyeballs 
within  the  socket,  together  with  exophthalmos.  The  vault  of  the 
cranium  projects  out  in  proportion  to  the  rest  of  the  skull,^so  that 
there  seems  to  be  enormous  enlargement  above  the  ears.  In  some 
cases  the  sutures  are  seen  to  be  separated  and  the  Wormian  bones 
palpable.  The  "  hydrocephalic  cry,"  consisting  of  a  long,  deep  re- 
spiratory sound,  is  a  very  usual  symptom.  Percussion  over  the 
skull  will  frequently  produce  a  pseudo-tympanitic  note,  and  on  aus- 
cultation over  the  skull  a  distinct  bruit  can  be  detected  synchro- 
nous with  the  pulse-beat.  The  patient  may  finally  pass  into  a  con- 
dition of  tetany  and  die  from  exhaustion. 

Pathology  consists  of  subacute  ependymitis  with  excess  of 
serum  within  the  ventricles,  which  may,  as  indicated,  also  extend 
to  the  arachnoid. 

Prognosis. — This  is  bad,  as  a  rule.  In  the  acutest  forms  life 
becomes  extinct  within  a  few  months.  Occasionally  the  symptoms 
abate,  and  the  patient  is  left  with  the  chronic  enlargement  of  the 
head  which,  if  not  too  extensive,  will  not  produce  paralysis  of  the 
extremities  nor  any  considerable  degree  of  mental  impairment, 
the  rule,  however,  being  that  cases  will  result  in  imbecility  with 
the  general  symptoms  of  spastic  paralysis  of  childhood.  It  should 
be  remembered  that  this  is  frequently  a  congenital  condition,  which 
is  lit  up  soon  after  birth.  It  is  astounding  to  what  degree  the 
convolutions  may  be  pressed  upon,  and  life  and  fair  mentality  be 
preserved  in  a  small  number  of  cases. 

Treatment  is  hygienic,  medicinal,  and  operative.  Prophylac- 
tic measures  should  be  part  of  the  treatment — nourishment  of  the 
child  predisposed  or  born  with  the  condition  is  most  essential. 
Inunctions  of  cod-liver  oil,  with  the  idea  of  gaining  weight  and 
greater  resistance  to  diseases,  is  of  value.  Spasms  should  be  con- 
trolled by  chloral  and  bromides.  Sodium  iodide  is  especially  of 
service  in  infants,  being  less  liable  to  disturb  the  stomach.     It 


INFLAMMATION    OF    MENINGES  179 

should  be  given  in  two-drop  or  three-drop  doses  of  a  saturated  solu- 
tion, gradually  increased  to  the  physiological  limit.  Some  advise 
compression  of  the  skull  by  proper  bandaging  with  the  idea  that 
this  may  tend  favourably  against  the  formation  of  exudation. 
Should  symptoms  of  compression  develop,  however,  the  bandage 
should  be  removed  immediately.  Surgical  aid  through  craniec- 
tomy, or  tapping  the  ventricles,  under  antiseptic  precautions,  may 
be  of  value  as  a  dernier  ressort. 

Chronic  Hydrocephalus. — This  is  usually  the  result  of  the  acute 
form  of  hydrocephalus,  and  from  the  evidence  found  at  birth  in 
same  cases,  it  is  apparently  chronic  from  the  very  first — i.  e.,  it 
has  existed  some  time  in  the  prenatal  life  of  the  child.  The  signs 
here  may  first  be  noted  during  labour,  an  enlarged  head  being  the 
cause  of  dystocia.  More  frequently,  however,  the  hydrocephalus 
becomes  apparent  some  time  after  birth. 

Causes  of  this  condition  are  not  definitely  known.  The  pathol- 
ogy offers  no  direct  clue  to  the  nature  of  the  trouble.  The  lateral 
ventricles  are  greatly  distended,  but  the  ependyma  is  usually  clear, 
occasionally  granular  and  thickened.  The  chorioid  plexuses  are 
extremely  vascular.  The  third  ventricle  is  dilated,  as  is  also  the 
aqueduct  of  Sjdvius  and  the  fourth  ventricle.  The  quantity  of 
fluid  may  be  several  litres.    It  contains  salts,  albumin,  etc. 

The  cerebral  cortex  is  greatly  stretched,  and  over  the  middle 
region  it  may  measure  but  a  couple  of  millimetres.  The  basal  gan- 
glia are  flattened.  The  bones  are  extremely  thin,  and  the  Worm- 
ian bones  themselves  may  gradually  extend,  due  to  the  effect  on 
the  part  of  nature  to  fill  in  the  ga-p  of  the  widely  separated  edges 
of  the  bones. 

Symptoms  are  similar  to  those  of  the  acute  type,  although  not 
so  severe.  Convulsions  may  occur,  reflexes  are  increased,  the  child 
may  learn  to  walk  late,  but  ultimately  usually  becomes  feeble  and 
very  spastic.  The  mental  condition  is  widely  variable,  from  that 
of  the  ordinary  imbecile  to  that  of  average  intellect. 

Diagnosis. — The  rhachitic  head  should  be  told  from  that  of 
acute  hydrocephalus,  and  is  known,  too,  by  the  other  evidences  of 
the  enlargement  of  the  epiphyses  of  the  long  bones.  The  head  in 
rickets  is  usually  square,  and  not  round  or  globular.  The  sepa- 
ration of  the  bones  of  the  skull  is  not  usual,  nor  is  there  the 
tympanitic  note  produced  on  percussion  over  the  skull  nor  the 
bruit  heard  on  auscultation,  as  in  hvdrocephalus. 
12 


180 


TEEATISE    OX   NEEYOUS    DISEASES 


The  acquired  form  of  clironic  hydrocephalus  is  simply  the  re- 
sult of  acute  hydrocephalus,  but  is  said  by  some  writers  to  be 
primary,  essential,  or  idiopathic;  that  is  to  say,  it  comes  on  spon- 


i 


X, 


i 


'V   'y 


i 


J       I      I       i      i       '       '       ^      '       '      '      >       ^     -t 


Fig.  39.— Braix.    Case  of  Hydrocephalus  in  a  Child  of  Five  Years.    Size 
indicated  in  inches  (reduced). — (Howard  Hospital.) 

taneously  in  the  adult  without  observable  lesion.  Osier  quotes  the 
statement  of  Mr.  Whiteway  that  Dean  Swift  was  a  subject  of  this 
variety,  but  doubts  the  possibility,  and  assumed  that  his  ease  was 


INTLAMMATION    OF    MENINGES 


181 


probably  one  of  a  spurious  form  of  hydrocephalus,  ex  vacuo ;  that 
is,  within  the  arachnoid  alone.  ,  The  symptoms  of  the  acquired 
form  would  vary  with  the  time  in  life  of  its  development.  If 
developing  early,  the  symptoms  already  rehearsed  will  be  present; 
if  late  in  life,  the  patient  will  suffer  from  headaches,  the  gait 
becoming  gradually  irregular  and  ataxic;  with  a  spasticity,  how- 


FiG.  40.— Spastic    Diplegia    from    Chronic    Htdrocephalus   (Adult    Male). 
(Philadelphia  Hospital.) 


ever,  which  distinguishes  it  from  other  forms  of  gait.  In  some 
cases  there  will  be  prolonged  attacks  of  coma  with  slow  pulse,  due 
to  irritation  of  the  vagi  nuclei  by  the  pressure.  One  case  on  record 
is  reported  to  have  been  unconscious  for  three  months.  Optic 
neuritis  soon  supervenes,  and  in  the  worst  cases  rapidly  progresses 
after  once  begun.  Chronic  purulent  ependymitis  may  precede 
death  in  some  cases. 


182  TREATISE    OX    NEEVOUS    DISEASES 

Meningitis  serosa  is  a  type  distinguished  by  Quincke,  and  con- 
sists of  serous  meningitis  as  distinguished  from  ordinary  lepto- 
meningitis and  from  hydrocephalus.  Quincke  describes  the 
affection  as  coming  on  suddenly  in  children  with  intense  pain  in 
head,  signs  of  intracranial  pressure,  slow  pulse,  and  choked  disks. 
Retraction  of  the  head  exists,  without  fever,  however.  Some  cases 
are  much  more  insidious  and  are  frequently  mistaken  for  brain 
tumour. 

Treatment  consists  in  the  relief  of  pain  and  in  making  an  effort 
to  cause  absorption  of  the  collected  fluid.  This  will  be  best  done 
by  giving  depletive  remedies,  such  as  gamboge  in  stlienic  individ- 
uals, or  podophyllin  or  even  calomel  in  repeated  dosage.  For  the 
more  usual  asthenic  cases  such  harsh  treatment  cannot  be  carried 
out,  and  we  must  depend  upon  free  diuresis,  producing  in- 
creased action  of  the  skin  through  such  drugs  as  pilocarpine. 
Potassium  iodide  is  a  valuable  remedy  as  a  sorbefacient.  Bichlo- 
ride of  mercury,  added  to  the  above  iodide,  may  favour  resorp- 
tion of  the  exudate  within  the  brain.  As  a  prophylactic  measure 
the  patient  should  be  carefully  guarded  against  inclement  weather 
and  given  nutritious  diet;  and  mental  strain  should  be  avoided. 
Skilled  massage  may  be  of  value  in  these  cases. 


CHAPTEE    X 
DIFFUSE  AND  LOCAL  DISEASE  OF  THE  BRAIN 

Cerebral  Localization  (Epitomized). — It  must  be  remembered 
that  cerebral  localization  is  not  an  exact  science,  because  symptoms 
may  also  be  produced  by  compression,  causing  irritation,  paresis, 
or  paralysis  of  adjacent  centres ;  also,  that  circulatory  disturbances 
occurring  in  the  course  of  disease  of  the  membranes  of,  or  of  the 
encephalon  itself,  may  cause  wide-spread  functional  disturbance 
that  disobey  all  scientific  rules.^  Still,  in  the  majority  of  instances, 
close  day-to-day  study  of  the  case  will  be  rewarded  by  brilliant 
diagnoses,  and  help,  therefore,  for  the  patient.  The  accompany- 
ing illustrations  (Figs.  41  and  42)  give  the  respective  locations  of 
the  definitely  know  centres  in  the  cerebrum.  Beginning  from  the 
posterior  aspect,  we  will  enumerate  the  function  of  each  centre 
and  lobe  (for  fuller  description,  see  Chapter  I,  on  Anatomy,  etc.). 

Occipital  Lobe. — Here  lie  the  centres  of  vision,  destruction  of 
which  causes  cortical  blindness  (in  the  absence  of  lesion  of  the  eye 
or  optic  nerve).  Hemianopsia  may  also  result  as  indicated  under 
diseases  of  the  optic  nerves.  Sensory  centres  are  also  present  in 
the  occipital  lobe.  (Cortical  centres  concerned  in  speech  are  de- 
scribed under  Aphasia.) 

Temporal  Lobe. — Here  lies  the  centre  of  audition — i.  e.,  for 
word  hearing — in  the  posterior  part  of  the  firsst  and  second  convo- 
lutions— and  the  centre  for  naming  in  the  third  convolution. 

The  central  convolutions  of  the  parietal  and  frontal  lobes  of 
the  cerebrum  are  principally  centres  for  voluntary  motor  func- 
tion. The  upper  portion  of  the  first  and  second  frontal  govern 
movements  of  eyes  and  head.    These  centres  overlap  one  another. 

These  convolutions  probably  also  receive  sensory  impressions 
from  the  skin,  muscle,  and  very  likely  from  the  viscera,  and  thus 

^  See  Some  Points  on  Intracranial  Neoplasms  considered  from  the  Neu- 
ronic Standpoint,  by  the  author.  Read  before  the  Section  on  Medicine,  New 
York  Academy  of  Medicine;  Philadelphia  Medical  Journal,  November  16, 
1901. 

12*  183 


184 


TREATISE    0^   NEEVOUS   DISEASES 


are  the  cortical  sensory  centres  for  muscle  and  tactile  sense,  the 
superior  parietal  lobule  being  probably  the  location  where  sensa- 
tions from  the  muscles  are  received. 

Irritative  lesions  in  the  motor  cortex  cause  local  spasms  ( Jack- 
sonian  epilepsy),  or  general  convulsions.  There  may  also  be  par- 
aesthesia  of  the  parts  convulsed,  due  to  vaso-motor  paresis. 


Superior  frontal  sulcus. 


Fissure  of  Rolando. 


Interparietal  sulcus. 


Ascending  ramus 
of  the  fissure 
of  Sylvius. 

Fissure  of 
Sylvius. 


Posterior  ramus  of  the 
fissure  of  Sylvius. 


Superior  temporal 
sulcus. 


Fig.  41.— Schematic  Representation  of  the  Cerebral  Cortex  and 
ITS  Centres.     (After  Tillmanns.) 


1.  First. 

2.  Second. 

3.  Third. 

4.  Anterior. 

5.  Posterior. 

6.  Upper. 

7.  Middle. 

8.  Lower. 

9.  Upper. 
10.  Lower. 


>  Frontal  convolution. 


Central  convolution. 


)- Temporal  convolution. 


Parietal  convolution. 


11.  Gyrus  angularis. 

12.  Upper.         ) 

13.  Middle.        r  Occipital  convolution, 

14.  Lower.         ) 


-^  In  4  and  5  on  both  sides  of  the  fissure  of 
O        Eolando,    motor    area  for    the    upper 

extremity. 

Motor  area  partly  for  the  upper  and  partly 
0        for  the  lower  extremity  ^gTeat  toe). 

Motor  area  for  the  lower  extremity. 
^  Cortical  area  for  the  hypoglossal  nerve. 
®  Cortical  area  for  the  facial  nerve. 

e 

Q  (3)  Motor  aphasia. 

X(6)  Sensory  (auditory)   aphasia  with  word- 
deafness. 

I   (11)  Aphasia  with  word-blindness. 

(12)  Region  of    the    visual    area    (see  also 
*  Fig.  10;. 


Destructive  Zesions. involving  these  same  central  motor  convo- 
lutions cause  paralysis  of  the  muscles  of  the  opposite  side  of  body, 


DIFFUSE   AND   LOCAL   DISEASE   OF   THE   BRAIX    185 

which  soon  become  spastic.  The  paralysis  is  not  always  complete, 
since  only  a  few  centres  may  be  involved.  Muscles  acting  together 
(as  of  respiration)  or  those  which  express  emotion  (as  the  facial), 


Fig.  43. — View  of  the  Right  Cerebral  Hemisphere  from  the   Median  Side. 

B,  corpus  caUosum  divided  longitudinally ;  G./.,  gyrus  fornicatus ;  H,  gyrus  hippocampi ; 
S.h.,  sulcus  hippocampi ;  G.  m.,  gyrus  uncinatus;  .§.  c.  m.,  sulcus  calloso-margiuaUs  ;  F.  1, 
first  frontal  convolution;  .S'.  c,  termination  of  the  fissure  of  Kolando;  in  front  the 
anterior  central  convolution  with  the  motor  area  partly  for  the  upper  and  partly  for 
the  lower  extremity,  and  behind  the  posterior  central  convolution  with  the  motor  area 
for  the  lower  extremity  ;  P,  prsecuneus  ;  C,  cuneus  ;  F.  po.,  pari eto- occipital  sulcus ;  p, 
polus ;  F.  c,  calcarine  fissure ;  in  the  posterior  part  of  this  the  visual  area  is  shown  by  a 
red  dotted  hue.    (After  Tillmanns.) 


being  represented  on  both  sides  of  the  cerebrum,  are  not  com- 
pletely palsied.  Asteriognosis,  or  disturbance  of  sensation,  may 
be  found  if  the  lesion  extends  to  the  posterior  part  of  the  parietal 
lobe. 

The  cells  of  the  ascending  frontal  or  precentral  convolution, 
the  ascending  parietal  or  post-central  convolution,  the  superior 
parietal  lohule,  the  upper  portions  of  the  first  and  second  frontal 
convolutions,  part  of  the  cuneus,  the  paracentral  lohule,  all  con- 
trol or  originate  voluntary  motor  impulses.  These  same  centres 
also  receive  sensory  impressions;  hence  this  region  of  the  brain  is 
designated  the  sensorio-motor  region.     The  trunk  muscles   and 


186  TREATISE    0^    NeeVOUS    DISEASES 

Ipg  muscles  are  largely  represen-ted  in  the  upper  portions  of  the 
precentral  and  post-central  convolutions.  The  muscles  ,of  the 
arm  have  their  centres  in  the  middle  third  of  the  precentral  and 
post-central  convolutions;  the  face,  tongue,  larynx,  and  pharynx 
being  represented  in  the  lower  part  of  these  same  gyri. 

The  Prefrontal  Region. — This  consists  of  the  part  of  the  fron- 
tal lobes  in  the  anterior  part  of  the  third  and  ascending  frontal 
convolutions.  The  centres  that  have  to  do  with  higher  mental 
faculties  (higher  psychical  centres)  lie  here — viz.,  those  of  judg- 
ment, reason,  memory,  attention,  and  comparison.  It  is  the  great 
association  centre  (Bianchi).  It  also  is  supposed  to  be  a  centre 
for  the  trunk  muscles,  according  to  Munk. 

Centrum  Ovale. — Lesions  here  may  involve  association,  sensory, 
or  motor  fibres.  A  subcortical  lesion  may  simulate  a  cortical  palsy, 
but  there  is  not  likely  to  be  spasm  at  any  time  except  after  inva- 
sion of  the  cortex.  Hence,  spasm  always  foUoivs  paralysis,  just 
the  opposite  to  that  in  cortical  lesions.  When  the  lesion  is  near 
the  internal  capsule  the  palsy  resembles  that  due  to  lesion  of  it. 
There  may  be  hemianopsia,  hemiansesthesia,  and  if  lesion  is  on  the 
left  side,  aphasia  in  disease  of  the  centrum  ovale. 

Corpus  Callosum. — ^Symptoms  are  of  partial  or  complete  palsy, 
a  hemiplegia  gradually  extending  to  the  opposite  side,  with  later 
development  of  dysphagia,  dysarthria,  and  an  insidious  dementia. 
A  double  cortical  lesion  may,  however,  closely  simulate  symptoms 
of  disease  of  the  corpus  callosum,  but  the  greater  asymmetry  in 
the  degree  of  muscle  weakness  would  be  in  favour  of  cortical 
disease. 

Corpus  Striatum. — The  function  of  this  ganglia  is  not  defi- 
nitely known.  It  is  very  likely  that,  as  excision  experiments  on 
dogs  lead  to  suspicion  of  (and  in  a  case  under  the  care  of  Dr. 
John  M.  Swan  and  the  writer,  one  of  Friedreich's  disease  with  tem- 
perature, which  seemed  to  point  to  its  degeneration  as  a  cause  of 
the  pyrexia)  the  existence  of  a  centre  for  heat,  regulation  is  in  the 
striatum.      ' 

Optic  Thalamus. — This  important  ganglia  is  joined  with  the 
cortex  of  the  frontal,  temporal,  parietal,  and  occipital  lobes.  It  is 
the  site  of  the  ultimate  ending  of  the  optic  tracts  as  well  as  of 
some  sensory  fibre  neurones,  which  latter  extend  through  their 
axons  to  the  cortex.  Very  likely  the  main  centre  of  regulation 
of  body  heat  is  in  the  thalamus.     With  the  external  geniculate 


DIFFUSE   AND   LOCAL   DISEASE   OF   THE   BRAIN"    187 


hoclij  and  corpora  quadrigemina  the  posterior  part  of  the  thalamus 
forms  the  primary  optic  centre. 

The  corpora  quadrigemina^  with  the  other  two  bodies  just  enu- 
merated, form  the  primary  visual  centres.  The  remaining  part  of 
these  centres  control  the  reflex  movements  of  the  iris  and  ciliary- 
muscles.  The  posterior  bodies  also,  together  with  the  internal 
geniculate  bodies,  are  joined  with  the  cerebellum  and  auditory 
centres,  hence  control  in  part  sen- 
sations of  space  and  audition. 

Internal  Capsule. — The  motor 
and  sensory  projection  fibres  (or 
peduncular  fibres)  pass  within 
very  narrow  compass  through  the 
internal  capsule.  In  the  region  of 
the  "  knee  "  are  fibres  which  pass 
from  the  cortex  to  the  motor 
nerves  of  the  eye,  to  facial  and 
hypoglossal  nerves,  also  those 
fibres  which  pass  to  the  nuclei  of 
the  nerves  that  govern  the  other 
muscles  that  have  function  in 
speech,  which  are  supplied  by  the 
vagus.  The  pyramidal  tract  fibres 
lie  next  posteriori}^,  those  of  the 
leg  being  also  posterior  to  the 
arm.  Posterior  to  all  of  these  are 
the  fibres  that  transmit  common 
sensation  and  special  sense  im- 
pulses (hearing,  vision,  taste, 
smell). 

As  the  pyramidal  tract  fibres 
are  in  a  very  compact  mass  in  the  capsule,  a  lesion  here  produces 
hemiplegia  on  the  opposite  side  of  the  body,  monoplegia  being 
never  produced  by  such  a  located  lesion.  If  the  lesion  is  in  the 
posterior  part  of  the  capsule  hemiansesthesia  will  result,  associated 
or  not  with  homonymous  hemianopsia,  and  with  muscular  paresis. 

Cms  Cerebri. — A  lesion  of  the  crus  will  cause  spastic  palsy 
or  paralysis  upon  the  opposite  side  of  the  body,  with  palsy  of 
muscles  supplied  by  the  motor  oculi,  since  this  nerve  makes  its 
superficial  exit  from  the  crus.     The  optic  tract,  as  it  crosses  the 


Fig.  43. — Diagram  of  Motor  and 
Sensory  Representation  in  the 
Internal  Capsule. 

NL.,  Lenticular  nucleus.  NC,  Caudate 
nucleus.  THO.,  Optic  thalamus.  The 
motor  paths  ai'e  red  and  black,  the  sen- 
sory are  blue.  (From  Osier's  Practice  of 
Medicine.) 


188  TREATISE    OX    NERVOUS    DISExVSES 

crus,  may  also  be  affected,  producing  homonymous  hemianopsia. 
The  tegmentum  may,  however,  be  involved  without  disease  of  the 
fibres  of  the  crus,  in  which  instance  disturbance  of  common  and 
muscular  sensibility  may  occur  associated  with  ataxia  of  the  oppo- 
site side  of  the  body. 

The  Pons  Varolii  or  Bulb. — The  gray  matter  here  consists  of 
cells  which  form  nuclei  of  the  peripheral  neurones  of  the  motor 
division  of  the  fifth;  also  the  sixth  and  seventh  nerves.  The  pons 
is  the  centre  for  the  ascending  or  sensory  nucleus  of  the  fifth  nerve ; 
also  for  the  sensory  and  motor  tracts  on  their  way  to  and  from  the 
cortex.  There  are  also  neurones  in  the  pons  which  connect  with 
the  cerebral  and  cerebellar  cortices. 

Cerebellum. — Here  the  gray  ganglionic  masses  are  in  the  cen- 
tre, but  the  gray  matter  proper  is  upon  the  cortex.  The  vermis 
or  middle  lobe  is  alone  known  positively  as  to  function,  and  is 
joined  with  sensory  and  motor  paths  of  both  brain  and  cord,  the 
auditory  nerve,  some  of  the  nuclei  in  the  pons,  and  with  the  infe- 
rior olivary  bodies  of  the  medulla.  The  functions  of  the  cere- 
bellum are  not  definitely  ascertained  in  detail.  It  is  known  to 
take  part  in  maintaining  the  equilibrium  of  the  body,  in  muscular 
movements,  and  in  maintaining  our  relations  to  surrounding  ob- 
jects. Hughlings-Jackson  claims  that  disease  of  the  cerebellum 
causes  palsy  of  the  trunkal  muscles  also,  and  that  the  cerebellum 
maintains  muscle  tone. 

Medulla  Oblongata. — The  lower  motor  neurones  or  nuclei  of 
the  eighth  to  twelfth  cranial  nerves  lie  here,  except  the  spinal  root's 
centre  of  the  eleventh,  which  is  in  the  cord.  The  oblongata  is 
of  course  only  the  expanded  portion  of  the  cord,  and  the  cells 
lying  here  have  the  same  sort  of  function  as  do  those  in  the  gray 
matter  of  the  cord. 

In  the  medulla  are  also  found  reflex  and  automatic  centres 
controlling  the  respiratory  and  circulatory  functions,  secretion, 
and  the  visual  movements.  The  olivary  bodies  (.superior  and  in- 
ferior) are  small  masses  of  gray  matter  in  the  medulla,  and  are 
joined  with  the  basal  ganglia,  cerebellum,  and  cord,  having  to  do 
in  part  with  co-ordination  and  equilibrium. 

A  lesion  high  up  in  the  oblongata  may  damage  the  pyramidal 
tract  above  its  decussation  and  the  liypoglossal  nerve  upon  the 
same  side  as  the  lesion,  producing  an  alternate  paralysis. 

Affection  of  the  nuclei  "gives  rise  to  the  so-called  bulbar  symp- 


DIFFUSE   AND   LOCAL   DISEASE    OF   THE   BRAIN    189 

toms — those  of  glosso-lal)io-pharyngeal  paralysis.  Death  may  fol- 
low suddenly  from  involvement  of  the  respiratory  or  cardiac  cen- 
tres. Polyuria  or  glycosuria  may  also  result  from  chronic  lesions 
of  the  medulla. 

The  functions  of  the  occipital  lobe  have  been  mentioned 
under  diseases  of  the  optic  tract. 

Cortical  centres  concerned  in  speech  are  to  he  described  next 
under  Aphasia. 

APHASIA 

By  this  we  mean  disturbance  of  the  power  of  communication 
by  the  ordinary  signs  of  language.  The  word  aphasia,  which 
signifies  loss  of  speech,  is  the  general  designation  applied  to  all 
forms  of  defects  of  the  elements  of  speech  due  to  disease  of  the 
cerebral  hemispheres.  This  is  usually  a  lesion  involving  the  cor- 
tical centres  of  the  speech  mechanism..  Aphasia  is  to  be  distin- 
guished from  disturbance  of  speech  that  follows  mechanical  trou- 
ble with  articulation  due  to  lesion  of  peripheral  organs  or  nerves, 
and  also  from  speech  defects  due  to  the  lesion  of  the  cranial  nuclei 
or  of  the  association  and  co-ordination  tracts  of  speech  in  the  ob- 
longata, pons,  and  cerebellum.  Aphasia  is,  therefore,  limited  to  a 
partial  or  complete  loss  of  the  power  of  comprehension  or  expres- 
sion of  language.  It  is  divided  into  two*  classes — motor  and  sen- 
sory  aphasia.  The  former  may  be  designated  emissive,  and  the  lat- 
ter a  receptive  type.  Of  the  motor  form  we  have  subdivisions  con- 
sidered as  elementary^ — namely,  (1)  aphasia,  or  complete  motor 
aphasia,  (2)  agraphia,  or  inability  to  write. 

Of  the  sensory  form  we  have  (1)  word-deafness,  or  auditory 
aphasia,  and  (2)  word- blindness,  or  visual  aphasia.  Mills  desig- 
nates another  form  of  elementary  aphasia — namely,  verbal,  or  that 
variety  which  is  due  to  the  lesions  of  the  naming  centre.  Apraxia 
is  the  form  where  the  patient  is  not  able  to  understand  the  uses 
of  objects. 

Motor  Aphasia. — Aphemia,  as  Brocker,  Ross,  and  others  have 
designated  motor  aphasia,  is  divided  by  some  into  two  or  three 
forms,  the  first  being  strictly  limited  to  that  produced  by  lesion  of 
the  foot  of  the  left  third  frontal  convolution,  the  so-called  Broca 
convolution.  Broadbent  names  another  variety,  in  which  the  lesion 
is  at  the  foot  of  the  second  central  convolution  back  of  the  Broca 
centre.    Total  destruction  of  Broca's  convolution  in  right-handed 


190  TREATISE    OX    XERVOUS    DISEASES 

peojjle  makes  spoken  speech  impossible  for  a  time  at  least.  Later, 
the  hitherto  untrained  centres  in  the  right  third  frontal  convolu- 
tion develop.  Tlie  patient  may  thus  accjuire  or  regain  partially  the 
faculty  of  speech.  Usually,  however,  recovery  in  part  is  due  tq  the 
fact  that  the  centre  was  not  entirely  destroyed.  The  reason  for  the 
speech  centre  being  on  the  left  side  is,  theoretically,  assumed  to 
be  that  this  side  is  much  more  highly  developed  than  the  other, 
in  obedience  to  the  ^Drinciple  of  the  economizing  energy,  most  peo- 
ple being  also  right-handed.  Articiilative  ataxia  is  nothing  more 
than  the  old  ataxic  aphasia,  so-called,  or  the  asynergia  verbalis  of 
Lordat — i.  e.,  the  existence  of  incomplete  motor  aphasia,  which  is 


Fig.  44. — Zones  and  Centres.    External  Aspect.     Cerebrum.     (After  Mills.) 

generally  the  sequel  of  the  complete  form.  Most  cases  of  motor 
aphasia  also  suffer  from  agraphia.  This  loss  or  defect  may  be  due 
to  lesions  of  the  centre  for  word-seeing,  which  centre  is  placed  at 
the  caudal  extremit}^  at  the  second  or  medio-frontal  convolution, 
and  in  close  relationship  with  the  upper  or  mesial  boundary  of  the 
true  speech  centre.  True  agraphia  is  an  almost  invariable  result 
of  destruction  of  Broca's  centre,  however.  It  is  probable,  as  Wiley 
concludes,  that  motor  agraphia,  as  far  as  writing  with  the  right 
hand  is  concerned,  may  result  from  a  lesion  in  the  graphic  centre 
in  the  posterior  portion  of  the  second  frontal  convolution. 

Pantomime  study  is  only  second  in  importance  to  that  of 
spoken  speech  in  the  consideration  of  aphasia.  It  is  in  general 
a  part  of  speech,  and  so  closely  associated  that  disturbance  of 


DIFFUSE   AND   LOCAL   DISEASE    OF   THE   BRAIN   191 

speech  is  always  accompanied  by  disturbance  more  or  less  of  pan- 
tomime. 

Amemia  is  loss  or  impairment  of  power  of  expression  by  signs, 
when  due  to  cerebral  disease. 

Paromemia  is  confusion  of  the  signs  in  efforts  at  expression 
through  them. 

Sensory  or  Receptive  Aphasia. — This  is  considered  usually  as 
having  three  special  forms:  (1)  auditory  aphasia,  or  word-deaf- 
ness; (2)  visual  aphasia,  or  word-blindness;  (3)  and  apraxia,  also 
called  mind-blindness,  soul-blindness,  and  object-blindness.  Physi- 
ological investigations,  including  those  of  Ferrier,  prove  (1)  word- 
deafness  is  due  to  lesion  in  the  posterior  third  or  first  and  second 
temporal  convolutions,  as  verified  by  Mills,  who  contends  "  that  it 
is  not  complete  unless  the  corresponding  region  on  the  right  hemi- 
sphere is  also  impaired  or  destroyed."  Other  symptoms  present  in 
this  form  are  inability  to  read  aloud  correctly.  The  patient  is  un- 
able to  verify  what  he  reads  by  hearing.  In  the  complete  form  he 
cannot  echo  spoken  words.  Paraphasia  and  paragraphia  may  also 
be  present  in  these  cases,  as  may  also  verbal  amnesia,  and  as  may 
articulative  amnesia.  But  it  is  probable  that  in  some  of  these 
cases  the  amnesic  phenomena  are  due  to  the  involvement  of  the 
centre,  or  of  tracts  leading  from  the  centre  of  word-hearing  to  the 
conceptional  or  motor  centres.  Music-deafness  may  be  associated 
with  word-deafness.  But  from  the  fact  that  it  is  sometimes  pres- 
ent when  auditory  aphasia  is  absent,  it  is  assumed  that  in  some 
people  the  faculty  for  music  belongs  in  both  hemispheres  of  the 
brain  to  a  greater  degree  than  does  the  faculty  of  hearing.  Be- 
tween the  auditory  centres  at  the  base  of  the  brain  and  the  cortical 
auditory  centres  in  the  left  temporal  lobe  are  also  entering  tracts 
for  hearing.  A  lesion  of  these  tracts,  which  probably  go  from 
both  sides  of  the  brain,  will  give  rise  to  a  form  of  word-deafness. 
Lichtheim  has  placed  the  entering  auditory  tracts  chiefly  in  the 
left  temporal  lobe.  A  lesion  of  this  tract  will  cause  outer  word- 
deafness.  A  case  of  lesion  restricted  to  this  entering  tract  alone 
has  been  reported  by  Lichtheim.  We  must  have  entire  comprehen- 
sion of  cortical  anatomy  aphasia  and  complete  understanding  of 
the  auditory  path  before  this  matter  becomes  clear. 

(2)  Visual  localization,  like  auditory  localization,  has  also  cer- 
tain tracts  to  be  considered  from  an  anatomical  and  physiological 

point  of  view  before  we  can  understand  ambl5^opia,  hemianopsia, 
13 


192  TEEATISE    ON    KEEYOUS    DISEASES 

etc.  Henschen  believes  that  the  centre  for  the  macuhir  fiekl  lies 
in  the  calcarine  cortex.  There  is  also  doubtless  stored  near  the 
visual  centre  images  of  words,  letters,  and  probably  of  objects. 


Fig.  45. — Zones  and  Centres.     Mesal  Aspect.     Cerebrum.  (After  Mills.) 

This  is  likely  in  the  angiilo-occipital  region  or  on  the  lateral 
surface  of  the  hemisphere,  as  located  by  Ferrier.  Partial  destruc- 
tion will  produce  word-  or  letter-blindness. 

Alexia,  or  the  inability  to  read,  will,  of  course,  be  produced 
by  such  a  lesion  as  will  cause  agraphia  so  far  as  this  is  dependent 
upon  sight.  Patients  who  have  been  rendered  alexic  or  word-Mind 
(lesion  of  centre  for  word-seeing)  can  sometimes  write  their  names 
or  simple  words;  apparently  doing  so  through  touch  or  by  recog- 
nition of  psycho-motor  im.ages.  Between  the  primary  optic  cen- 
tres at  the  base  of  the  brain  and  the  cortical  centres  recited  are 
certain  entering  tracts  for  vision  (optic  radiations  of  Grateolet). 
It  must  be  remembered  that  the  primary  cortical  visual  centres  are 
connected  with  half  of  the  retina  on  each  side — the  same  half  on 
which  the  centre  lies — the  fibres  passing  to  the  angular  region  in 
each  hemisphere.  This  is  the  centre  of  eye  functions.  A  lesion 
which  severs  the  tracts  coming  from  both  occipital  lobes  to  higher 
centres  will  cause  word-blindness,  but  not  agraphia.  Commonly 
such  a  lesion  will  also  produce  hemianopsia,  since  the  radiations 
of  Grateolet  are  usually  involved. 

( 3 )  Not  infrequently  associated  Avith  word-blindness  is  another 
disorder,  wbich  has  been  variously  called  mind-Mindness,  soul- 
blindness,  and  object-blindness.    In  examining  for  this,  the  physi- 


DIFFUSED   AND  LOCAL  DISEASE   OF   THE  BRAIN  193 

cian  tries  to  determine  if  the  patient  shows  signs  of  recognition  of 
various  objects.  He  may  not  comprehend  the  use  of  the  simplest 
things  and  he  may  not  recognise  intimate  friends,  excepting  by 
touch  or  by  hearing  their  voices.  (Occasionally  there  is  added  to 
this  form  a  psychic  deafness  in  which  the  patient  cannot  recognise 
a  friend  by  the  sound  of  the  voice.)  The  centre  for  mind-blind- 
ness., may  or  may  not  be  separate  from  the  centre  for  visual  images 
of  words  (visual  aphasia).  Both  hemispheres  of  the  cerebrum 
doubtless  take  part  in  the  storing  of  images  in  equal  degrees.  The 
mental  percepts  of  objects  and  of  names  are  the  results  of  defi- 
nite processes  of  cerebration  (Mills).  Ideation  is  particularly  dis- 
turbed through  lesion  of  the  radiating  fibres,  whereas  the  determi- 
nation of  names  is  disturbed  through  lesion  of  the  centres  for  per- 
cepts only. 

Mills,  with  Broadbent,  holds  the  view  that  a  naming  centre 
exists  in  the  cortex  of  the  brain.  Destruction  of  this  centre  will 
produce  verbal  amnesia.  A  form  of  verbal  amnesia,  called  articu- 
lative  amnesia,  would  be  due  to  partial  destruction  of  this  centre. 

Conducting  aphasias  are  those   forms  of  speech  disturbance 


Fig.  46. — Plechsig's  Association  Areas — Lateral  Aspect. 


which  are  due  to  defects  or  destruction  of  the  tracts  associating 
various  regions  concerned  in  the  mechanism  of  speech.  Some  of 
these  are  parapliasia ;  paragraphia,  the  misuse  of  words  in  writing ; 
paramemia,  the  misuse  of  signs;  paralexia,  misuse  in  reading  of 


194  TEEATISE    ON    NERVOUS    DISEASES 

syllables  or  words;  and  dyslexia,  which  is  difficulty  or  fatigue 
shown  in  reading. 

Examination  for  Aphasia. — First:  determine  associated  phe- 
nomena of  aphasia,  as  gesture  language,  already  detailed.  Test 
for  these  carefully.  Second:  extra-graphic  symbols  should  be 
sought  Qut,  such  as  the  methods  of  implying  numbers,  algebraic 
signs,  etc.  Third :  the  determination  of  mind-blindness.  Fourth : 
emotional  and  intellectual  faculties,  which  include  determination 
of  emotion,  mentality,  etc.  Fifth :  motor  and  sensory  functions 
should  be  studied.    These  should  all  be  critically  observed. 


Fig.  47. — Flechsig's  Association  Akeas — Mesial  Aspect. 

The  definite  subheadings,  as  given  by  Mills,  are  as  follows : 
The  methods  of  (A)  spoJcen  speech  should  be  determined — 

1.  Inquiry  as  to  how  the  patient  receives  and  interprets. 

2.  (a)   How  is  it  produced?  making  a  record  of  words,  etc 
(&)  Evidence  of  amnesia  and  its  companionable  symptoms — artic- 
ulative  amnesia  and  paraphasia. 

3.  How  is  it  repeated  or  echoed? 
(B)  Written  Speech — 

1.  How  is  it  received  and  interpreted? 

2.  Is  sight  good,  is  hemianopsia  present  ?  etc. 

3.  How  is  it  produced? 

4.  Ask  the  patient  to  write  his  name. 

5.  How  does  the  patient  write  to  dictation  or  from  copy?  Try 
him  in  both  ways,  and  if  he  is  able  to  do  either  or  both,  try  to 
ascertain  if  he  understands  the  meaning  of  what  he  writes. 


CHAPTER   XI 
OTHER  DISEASES  OF  THE  BRAIN  AND  MEMBRANES 

GENERAL    SYMPTOMATOLOGY 

Theee  are  certain  general  signs  and  symptoms  that  are  found 
more  or  less  constant  in  almost  all  organic  diseases  of  the  en- 
cephalon.  These  symptoms  may  be  placed  in  five  classes:  (1) 
general  symptoms  of  brain  irritation;  (2)  general  symptoms  of 
brain  pressure;  (3)  symptoms  of  focal  irritation  or  destruction; 
(4)  symptoms  due  to  local  pressure;  and  (5)  those  due  to  the 
pathologic  process  itself. 

The  symptoms  of  brain  irritation  are  headache,  vomiting,  ver- 
tigo, photophobia,  mental  irritability,  insomnia,  a  sense  of  pres- 
sure and  fulness  about  the  head,  noises  in  the  ears  (tinnitus)  or 
in  the  head,  tenderness  of  the  scalp,  and  in  bad  cases  convulsions, 
paralysis,  or  delirium  and  stupor. 

Brain  compression  has  as  symptoms  headache,  vomiting,  men- 
tal hebetude  or  dulness;  or  it  may  be  some  form  of.  paralysis, 
contraction  of  pupils,  and  finally  coma.  Retraction  of  abdomen 
(scaphoid)  accompanied  by  constipation  is  often  present. 

Symptoms  of  brain  compression  may  be  associated  with  anae- 
mia, oedema,  or  increased  blood  pressure;  or,  indeed,  in  states  of 
malnutrition,  when  the  brain  mass  is  impoverished,  symptoms  of 
compression  may  prevail.  Irritation  and  pressure  symptoms  may 
inter  digitate,  so  that  at  times  it  is  impossible  to  differentiate  one 
from  the  other.  Encephalic  irritation  symptoms  are  usually  asso- 
ciated with  hypersemia. 

Focal  or  local  symptoms  depend  almost  absolutely  upon  the 
location  of  the  lesion  causing  them.  If  the  motor  area  is  af- 
fected, twitching,  spasm,  or  convulsion  would  be  likely  to  follow 
early;  while  when  destruction  at  the  same  site  occurs,  the  symp- 
toms will  be  of  paralysis.  If  in  a  sensory  centre  or  tract,  the  first 
symptom  would  be  of  paresthesia  or  hyperesthesia;  the  later  one 
being  of  anaesthesia  of  the  part  supplied  by  the  centre  involved. 

195 


196  TEEATISE    OX    XEEA^OUS    DISEASES 

Symptoms  due  directly  to  the  pathologic  lesion  itself  may  he 
meagre;  just  as  in  tumour  of  the  spinal  cord^  for  example,  the 
symptoms  of  irritation,  pressure,  or  even  destruction  or  local  dis- 
turhance  of  circulation  may  be  dwarfed  by  septic  infection.  Gen- 
eral symptoms,  the  result  of  septicaemia,  such  as  chill,  fever,  sweat- 
ing, etc.,  may  become  paramount. 

Hemiplegia  and  aphasia  are  symptoms  that  may  be  caused  by 
so  many  different  kinds  of  lesions  that  they  demand  some  special 
study  here.  Both  groups  of  symptoms  pertain  in  general  to  motor 
or  sensori-motor  disturbance. 

Hemiplegia,  is  paralysis  of  one  half  of  the  body,  as  a  rule  in- 
volving the  side  opposite  the  lesion.  The  arm  is  usually  the  most 
palsied,  the  leg  next,  and  the  face  least.  Hemiplegia  may  be  acute 
or  of  slow  onset,  the  former  being  due  to  hsemorrhages,  cerebral 
softening,  or  more  rarely  to  injuries  or  to  inflammations.  The 
latter  is  usually  very  insidious,  and  is  generally  caused  by  tumours 
or  slowly  developing  areas  of  sclerosis ;  but  this  may  be  only  a  part 
of  diffuse  sclerosis.  The  particulars  of  hemiplegia  will  be  given 
under  Special  Diseases  of  the  Brain. 

MALFORMATIONS    OF    THE    BRAIN    AND    ITS 
MEMBRANES 

There  is  little  practical  importance  to  this  subject  as  regards 
congenital  malformations,  since  in  most  cases  the  monsters  die — a 
most  fortunate  result.     The  following  are  some  of  the  types : 

Brain. — Anencephaly;  micrencephaly  and  microcephaly;  por- 
encephaly; malformations  or  absences  (cyclopia). 

Brain  and  Membranes. — Acrania;  meningocele;  encephalocele ; 
hydrencephalocele. 

With  acrania,  anencephaly  is  always  present.  In  anencephaly, 
the  cerebellum  and  part  of  the  basal  ganglia  existing  may  permit 
the  child  to  live  for  a  -hort  time  after  birth.  In  micrencephaly 
the  brain  is  but  partly  developed;  and  if  in  addition  the  cranium 
is  also  abnormally  small,  as  is  generally  so,  the  name  microcephaly 
is  given.  This  is  due  to  lack  of  growth  of  the  brain,  and  probably 
not  at  all  to  premature  growing  together  of  the  cranial  bones,  as 
once  contended  by  Virchow.  If  the  circumference  of  an  adult 
cranium  is  less  than  42  centimetres  it  will  contain  a  micrencephalic 
brain.      iSTormallv   the   weight    of   an   adult    man's   brain   is    960 


DISEASES    OF    THE    BEAIX    AXD    MEMBEAXES  197 

grammes,  while  880  grammes  is  the  weight  of  an  adult  woman's 
brain.  It  is  14  per  cent  of  body  weight  at  birth  and  2.4  per 
cent  at  adult  life.  Porencephaly  is  often  the  result  of  hsemor- 
rhage.  In  cyclopia  there  is  an  undivided  anterior  cerebral  vesicle, 
and  the  orbits  form  a  continuous  cavity  with  a  single  rudimentary 
eye.  Meningocele  is  a  hernia  of  the  brain  membranes.  In  en- 
cephalocele  the  brain  also  protrudes  through  the  cleft  in  the  skull. 


Fig.  i8.— Lack  of  Development.    Left  Half  Cerebrum.    (Specimen  from 
woman  at  the  Philadelphia  Hospital.) 

These  forms  usually  occur  in  the  occipital  region  and  in  the  me- 
dian line.    In  hydrencephalocele  there  is  a  sac  with  fluid  contents. 

MENINGOCELE 

This  may  be  either  of  the  membranes  of  the  brain  or  of  the 
cord.  It  consists  in  the  protrusion  of  the  meninges  out  of  the 
natural  position  within  the  skull  or  spinal  cord.  In  the  case  of  the 
brain,  where  there  is  also  an  existent  internal  hydrocephalus,  the 
distended  ventricle  may  form  a  part  of  the  tumour,  in  which  case 


198  TEEATISE    OX    NEEVOUS    DISEASES 

it  is  then  designated  a  hj^drencephalocele.  Usually  such  tumours 
are  covered  with  the  skin  of  the  scalp.  At  other  times  they  are 
devoid  of  the  cutaneous  covering.  The  most  frequent  position 
for  the  appearance  of  these  tumours  is  in  the  anterior  portion 
of  the  skull^  very  seldom  occurring  at  the  base  of  the  brain.  This 
is  largely  on  account  of  the  thinness  of  bone  and  the  position  of 
the  fontanelle  openings.  The  hernia  is  caused  by  increased  cere- 
bral pressure  from  within,  due  to  excessive  fluid,  and  frequently 
to  teratological  defects  as  the  primary  cause.  Adhesion  of  the 
amnion  to  the  cephalic  end  of  the  embryo  is  probably  an  impor- 
tant factor  in  the  production  of  the  congenital  condition  type. 
Disease  of  the  meninges  in  early  life  may  be  the  cause  of  some 
acquired  cases.  Sex  has  no  influence  in  their  production.  Ma- 
ternal impressions  and  fright  are  said  to  be  exciting  causes  of 
these  malformations.  .  Usually  the  length  of  life  in  infants  affected 
with  this  deformity  does  not  extend  beyond  one  year.  Cases  have 
been  reported,  however,  where  they  reached  adult  life. 

Symptoms. — Membranes  protrude.  Drowsiness  and  mental 
enfeeblement,  also  paresis  and  convulsions,  are  the  most  impor- 
tant symptoms. 

Pathology. — ^Usually  the  condition  is  an  embryological  defect. 
If  disease  of  the  membranes  has  been  the  primary  cause,  the  path- 
ological condition  or  cause  will  be  that  of  the  primary  disease, 
such  as  meningitis,  acquired  hydrocephalus,  etc. 

Treatment. — This  is  most  uncertain.  If  the  protruding 
mass  is  small  it  may  either  be  excised  by  the  surgeon  or  com- 
pressed into  the  cranial  vault.  Some  authorities  have  advised  the 
withdrawal  of  the  fluid  in  the  sac;  and  where  the  membrane  ex- 
truded is  quite  isolated  from  that  within  the  skull,  injection  of 
carbolic  acid,  with  the  hope  of  setting  up  subacute  inflammation, 
which  may  shrivel  the  mass  in  question,  can  be  tried. 

APOPLEXY  (CEREBRAL  HiCMORRHAGE) 

By  this  term  is  generally  understood  hsemorrhage  into  some 
part  of  the  brain,  and  in  the  majority  of  instances  the  bleeding  is 
from  the  lentieulo-striate  arteries.  These  supply  nutriment  to  the 
motor  cortex  and  important  ganglia  at  the  base  of  the  brain,  from 
which  projectile  fibres  extend' to  the  spinal  cord  and  transfer  nerve 
energy  to  the  lower  neurons  and  extremities. 


DISEASES    OF    THE    BKAIX    AKD    MEMBRANES  199 

Apoplexy  is  sometimes  called  a  "  stroke,"  or  "  paralysis  " ;  and 
while  paralysis  is  the  usual  result  of  a  hsemorrhage  into  the  central 
nervous  system,  it  is  more  exact  to  speak  of  apoplexy  than  any  of 
the  other  terms  commonly  used  by  the  laity.  The  physician  under- 
stands a  broader  definition  of  apoplexy  even  than  that  above  given 
— i.  e.,  thrombosis  of  cerebral  blood-vessels,  or  embolism,  either, 
though  more  limited,  practically  produces  similiar  signs  and 
symptoms ;  ,the  former  insidious,  the  latter  sudden.  As  the  treat- 
ment of  these  three  conditions  would  not  much  vary,  it  will  be 


Anterior  cerebral 


Middle  cerebral 


Sylvian 

Posterior  cere- 
bral 


Lenticulo  optic 

Lenticulo  striate 
set  of  arteries 

Internal  carotid 


Basilar 


Vertebral 


Fig.  49. — Showing  Arteries  at  the  Base  of  the  Brain.  One,  the  lenticulo- 
striate,  is  called  the  artery  of  cerebral  hemorrhage.  (Slightly  modified  from 
Dercum.) 

unnecessary  to  more  than  mention  them.  The  predisposing  causes 
of  true  apoplexy  are  in  the  following  order  of  occurrence :  first, 
chronic  alcoholism;  secojid,  syphilis;  tliird,  other  infectious  dis- 
eases. The  predisposition  to  cerebral  hsemorrhage  with  what 
might  be  called  normal  sclerosing  or  hardening  of  the  vessel  walls 
due  to  advancing  years,  must  be  considered ;  and  here  it  is  espe- 
cially that  heredity  plays  an  important  role  in  etiology.  In  pro- 
portion, then,  as  persons  past  middle  life  develop  arteriosclerosis, 
will  the  tendency  to  this  serious  malady  occur.  Induced  plethora 
from  overeating  is  a  predisposing  cause.  Physical  and  mental 
strain  are  exciting  causes.     Night  or  early  morning  hours  are  the 


200 


TEEATISE    ON    NEEVOUS    DISEASES 


most  favourable  times  for  cerebral  hasmorrhage,  and  especially  for 
embolism  and  thrombosis.  Singularly,  it  often  happens  when  the 
patient  has  been  feeling  particularly  "  well,"  although  it  will  be 
found  there  have  been  some  days  or  months  of  sense  of  vertigo 
with  fleeting  attacks  of  congestion  of  the  brain.  The  attack  may 
appear  in  such  a  predisposed  individual  following  exertion,  strain- 
ing at  stool,  or  after  partaking  of  a  hearty  meal. 

Signs  of  Attack. — Eather  sudden  loss  of  consciousness  pre- 
ceded by  thickness  of  speech,  or  motor  aphasia,  accompanied  with 
flushing  of  the  face,  extreme  objective  vertigo,  followed  by  falling 


Fig.  50 — Showing  the  Portions  of  the  Cekebral  Hemispheres  Supplied  by 
THE  Anterior,  Middle,  and  Posterior  Cerebral  Arteries.  (Redrawn 
from  Dana. ) 


in  unconsciousness  if  the  patient  is  standing  or  sitting.  With 
this  there  is  more  or  less  stertorous  breathing,  and  perhaps  clonic 
convulsions  will  precede  the  ultimate  paralysis,  which  is  usually 
of  one  side  of  the  body,  owing  to  the  location  of  the  hsemorrhage 
on  the  opposite  side  of  the  cerebrum.  It  will  be  found  within  a 
half  hour  that  the  temperature  of  the  patient  has  risen  slightly,  the 
coma  becomes  more  profound,  following  the  marked  restlessness 
which  is  seen  just  after  the  stroke.  There  is  slight  hypersesthesia 
of  the  paralyzed  side,  as  shown  in  a  few  cases  where  the  coma  is  not 
too  profound.  The  increase  of  temperature  is  more  pronounced  on 
the  affected  side,  and  averages  half  a  degree  by  the  axillary  record 


DISEASES    OF    THE    BKAIN    AND    MEMBRANES  201 

or  less  by  surface  thermometers.    Hyperpyrexia  may  rarely  occur, 
and  is  always  an  unfavourable,  usually  a  fatal  sign   (Fig.  53). 


i  « 


The  paralyzed  extremities  when  raised  from  the  couch  will  drop 
flail-like;  the  patient  occasionally,  on  partial  recovery,  will,  how- 
ever, be  able  to  move  the  other  side  of  the  body.    There  may  also 


202  TREATISE    OX    XEEVOUS    DISEASES 

be  retention  of  urine,  wMch  must  be  guarded  against  by  the  nurse. 
The  deep  reflexes  on  the  paralyzed  side  are  always  diminished  or 
absent  in  this  stage.  Conjugate  deviation  of  the  eyes,  or  a  turn- 
ing of  the  eyes  away  from  the  paralyzed  side  in  cerebral  lesions, 
may  exist;  or  the  eyes  may  remain  "fixed."  If  convulsions  occur 
the  "  deviation  "  of  head  and  eyes  may  be  towards  the  palsied  side. 

At  the  end  of  three  or  four  hours,  if  the  case  does  not  go  to  a 
fatal  issue,  the  patient  begins  to  improve.  The  coma  now  becomes 
less  profound,  the  reflexes  appear  again  in  the  paralyzed  side,  the 
patient  may  recover  power  in  muscles,  perhaps  an  extremity,  and 
he  may  turn  from  the  supine  position  in  which  he  lay  to  one  or 
the  other  side.  Here  the  nurse  should  be  instructed  as  to  care  to 
prevent  pressure  paralysis,  which  may  be  caused  by  lying  upon  the 
enfeebled  arm.  The  chronic  stage  now  sets  in.  Gradual  restora- 
tion of  speech  takes  place  in  the  majority  of  cases,  although  there 
may  remain  some  form  of  dysarthria,  as  "  thickness  "  of  speech,  for 
some  months  in  even  the  most  promising  cases  for  large  recovery 
of  power.  There  remains  difficulty  in  swallowing,  and  the  saliva 
may  dribble  from  the  mouth  for  some  months.  As  a  rule,  the 
tongue  is  protruded  towards  the  paralyzed  side  and  the  face  drawn 
towards  the  sound  side,  although  there  is  no  disturbance  of  taste. 

The  muscles  of  the  paralyzed  side  do  not  degenerate  in  the 
sense  of  showing  "  reaction  of  degeneration "  by  the  galvanic 
current,  and  there  is  rarely  true  trophic  wasting,-only  that  due  to 
disuse  of  the  affected  members.  In  the  average  case,  at  the  end  of 
a  few  weeks,  the  patient  Avill  be  able  to  move  about  with  the  assist- 
ance of  crutches  or  cane.  The  manner  of  progression  will  be  typ- 
ically characteristic  of  the  so-called  hemiplegic  gait.  The  affected 
limb  is  thrown  out  and  forward,  describing  the  arc  of  a  circle,  and 
then  the  foot  is  dropped  down  flail-like  upon  the  ground.  This 
peculiarity  in  walking  is  caused  by  the  patient  throwing  his  trunk 
forward  and  to  the  sound  side,  due  to  the  fact  that  the  extremity 
being  paralyzed,  compensatory  movements  and  muscular  effort 
must  be  made  by  the  other  limb.  Substituting  this  flaccid  hemi- 
plegic gait,  in  the  course  of  a  few  weeks  there  develops  in  the 
patient  spasticity  of  the  muscles  of  the  affected  side ;  and  then  the 
paralyzed  member  will  be,  with  the  partially  regained  power, 
pushed  along  in  a  spastic  fashion,  the  toe  being  "  dug  "  into  the 
ground. 


> 

i 

-0    2o     DETAILS 

OF  TREATMENT 

§„       g,       8„       2        1        i 

CLINICAL  MEMORANDA                1^ 

iS 

20 

21 

«;  ■ 

14 

1            1  1    -t- 

MI-4--LL  II          _LL  1 

30 

114 

1  1      1 

III      i      II      II            --Jda  a!m.                             1 

•;ii 

dn 

cM'  '     ' 

1  ,          11   ___^__!_  Js'^  -    . 

30 

88 

!►=;■ — '       !  1     1 

-- 

»R 

96 

1 

h  t     .1.        ^---08  j.  ,.[ 

•-. 

1        1    1-    ^  i 

26 

G8 

ll>.eP.M.                                        ..^ 

:■■■-■■-  f'  -■■  '"  ■  -  ■ 

38 

108 

S  1  1       : 

1 

. 

1 

~~ 

~^ 

Mi            '~  ^^^ 

.  p.\. 

32 

108 

i         ,S,P.M.(  l^!"^ 

,, 

"T*^ 

~~ 

~~ 

1                         11. -    ;   ■■  ■  ' 

~ 

.;    .■  s  ■  j  1 .'    E 

-  C  -  1 

1-^^ 1 



^~ 

■•-■■-:(-        1 

_ 

„ .^  ■..:;■■     1      1 

7~ 

"7~ 

!•■  -    t  -     - 

!3S3i&iinL 

1      i            1 

-        1                                           ^^.^  ?  » ,^  .                           '! 

40 

108 

^>^a!m.                                                ■' 

^■-=^111 

'■  '  ■''  '■■''  '■"  "  "  ■■ 

1 

1     1  ""^  ■  ■■  -LL 

: — 

-~~ 

1  1 

1      '    TTirsit^  ::              .      . 

~~ 

1   -sS:"^   'Ml       1       I 

-; 

1  :  -       1                                   ~^~..          1       1 

40 

92 

£                -j                                                                          ><  1  G  P.M. 

'^      i    i    i 

"~ 

.:,,-, 

j                 '  ^=5' 1       i   1       1   1   M 

-^:^ 

V-.. 

1  ;                    — 

=^         !    ' 

'^~ 

4,. 

v|i-,-  ;|  .  = 

-    ■•    I                                                               1    '        y- 

:                   ! 

~~ 

"^-■'                      l<>:l  • 

-    -1   r  -■  ''-^^'^'^ 

"ml 

114 

■:            1      '■ 

:!                                                       8  A  M.(  iC^   i         1    !     1    1         1 

1    "1^^"  '   -  '   -  - 

hi;  "T^-lL  i 

■  --  -  \  --  '1    -  '  ■ 

j      1      !,*>    i 

! 

T~ 

~ 

-rTT'  1  1     1 

1 

- 

28 

114 

8  P.M.  ,  Li.^          II 

1  ^  54 

1 

a 

■■  '■'  <  <rr'  "  1 

__ 

::::::: !«s-^ 

-'     t                        .      ^ 



24 

84 

.8A.M. 

::::        :  :::::?^;::: 



----^ 

32 

~80 

-  ■  JH 

jWam. 



■  '   )       ■ 

. 

~~ 

; 

^       1 

^ 

;^  1    II               """' 

24 

84 

--       T^.ba.«. 

T    T       '  • 

1  1   ^    ■  1 

T- 

;- 

"""  1  Tr—==:^^]:^::::::::__. 

_ 

.-. 

32 

80 

-    1  1    ;r6P.M. 

-=  :-i  -  rT'-^  ■■-          H 

l^r-                     -- 

-'•     1  ■-    "F    ■  "- 



--  M 

1 



.  e^   ■ 

..        -1        -:■        -    --■      -  'M' 

24 

80 

T"*  8  aIm 

i                   1 

1        L 

4-  ' 



T"  -i--                 1 

. 

:   . 

ri-! 



30 

104 

1                       ^J-l»l  '8  P-M 



28 

94 

a 

8  A  M.(  1^^             1    1 

~7^ 

~-J^-| 

"32^ 

loo 

f  Y  )!C  fE 

Gi.  ;iii.     ;    "                      i)»6  P.M 

30 

104 

,    ■,  oi'm; 

fl.'<l-r|-             RAM^i.J           1 

'- 

— 

-,-1 

- 

R  ;!T  .E5. .    >,■  D  ND  S  ' 

T^ 

,>.^,. 

"32 

120 

:::::::::::::::::__-->,^- ! 



40 

140 

11 

8AM.i<_.I.M             1 

— 

-rrr 

:  ,     1  ;  !  ,   — 

P^             __^     i     _     1     

1 

:            . Ji''"'^ 

loT  130 

L^  "^  j.  '  r "      i    i          1 

[-     ,        =-:..:..: 

ii 

|6P.M.(<;;^    1                 1        '• 

|-                -             "     - 



: 

It         '  _Z5 "      '  ■'         11 

-T            ■"    ■     - 

~~ 

~ 

1  -  .■    '^::d'^\                             1 

-I        '     -  .      -      -  ■       " 



_ 

-; 

1     1  1             ' #    !           ' 

1       '  1  '         -  • 

40 

160 

1  1 

!         i    1                                           4f8I..M.,DIED      i 

1      1    • 

o 

I  I   I  I  I  I  I'l  I  I  I   I  I  I  I  I  I  I  I  I   I  I  I  I  I  I  I  M  I  M  I  II  I  I  I  I  I  I  I  I  M  I  I  M  M  I  I  I  I  I  I  I  I  II  M   I 


'204.  TREATISE    OJT    NERVOUS    DISEASES 

The  affected  arm,  which  has  thus  far  himg  flail-like,  improves 
more  slowly  as  to  power  than  does  the  lower  limh;  hut  with  the 
return  of  power^  flexion  of  the  elhows  and  fingers  takes  place. 
This  is  due  to  secondary  contraction  of  the  flexor  muscles,  which 
are  disproportionately  increased  in  power  over  the  extensor  group 
of  muscles.  In  the  course  of  the  affection  there  will  be  found 
secondary  degeneration,  and  this  may  extend  to  the  opposite  side 
of  the  spinal  cord,  causing  great  increase  of  the  deep  reflexes  on 
both  sides  of  the  body.  As,  the  case  progresses,  joint  symptoms 
are  not  unusual ;  the  disuse  of  the-  joint  and  lowered  trophic  con- 
dition sets  up  a  low  grade  arthritis,  the  affected  joint  becomes 
painful  and  semi-ankylosed.  Subacute  neuritis  in  the  affected 
extremity  may  also  be  set  up.  Great  wasting  of  the  extremity 
is  the  exception.  There  is  never  reaction  of  degeneration  in  the 
paralyzed  muscles  in  cerebral  lesions,  as  already  referred  to  in  a 
previous  paragraph.  Sweating  upon  the  paretic  side  of  the  body 
is  not  a  usual  symptom,  but  when  present  shows  vaso-motor 
weakness.  The  following  hygroscopic  observation  has  been  made 
for  me  by  Dr.  H.  E.  Wetherill : 

Case  of  M.  K.,  aged  thirty  years,  female:  Right  palm,  82.5 
per  cent;  left  palm,  96.0  per  cent;  abdomen,  2  inches  above  umbili- 
cus, 84  per  cent ;  mid-scapular  region,  Wurtzer's  uncovered  instru- 
ment, 70  per  cent;  temperature  by  the  mouth,  98.3°  F. ;  tempera- 
ture of  the  ward,  corrected,  72°  F. ;  relative  humidity  of  air  of 
ward,  84  per  cent ;  barometric  pressure,  corrected,  30.045  inches. 

Result  in  this  one  case :  "  It  would  appear  that  the  skin  moist- 
ure is  increased  in  the  diagnosed  condition  of  left  hemiplegia,  not- 
withstanding it  was  a  damp  day." 

PafJiology. — The  haemorrhage  is  generally  due  to  disease  of  the 
blood-vessels,  which  is  usually  a  degenerative  arteritis : 

First,  attacking  the  media.  Miliary  aneurysms  form.  The 
aneurysms  occur  most  frequently  upon  the  cortical  vessels,  and 
may  also  extend  to  the  smallest  arterioles.  On  section  of  the  brain- 
substance  they  appear  as  localized,  dark  bodies  about  the  size  of  a 
pin's  head. 

Second:  Endarteritis  and  perim-teritis  may  lead  to  apoplexy, 
either  by  producing  miliary  aneurysms  or  coarse  ones  of  the  larger 
vessels,  as  of  the  circle  of  Willis. 

Third:  Fatty  degeneration  of  the  small  vessels  occurring  in 
purpura,  scurvy,  leucocythsemia,  marasmic  conditions,  and  acute 


DISEASES    OF    THE    BRAIK    AND    MEMBRANES  205 

infectious  diseases.  Atheroma  is  usually  found  in  the  larger 
vessels. 

The  parts  affected  in  haemorrhage,  in  the  order  of  frequency, 
are  the  caudate  and  lenticular  nuclei,  meninges  and  cortex,  cen- 
trum ovale,  optic  thalamus,  pons,  cerebellum,  and  medulla.  Ven- 
tricular haemorrhages  are  usually  secondary  to  hemorrhage  into 
the  neighbourhood  of  the  basal  ganglia. 

After  a  haemorrhage  there  is  first  coagulation  of  the  blood, 
which  soon  begins  to  soften  and  be  absorbed.  The  inflammation 
occurring  about  the  clot  usually  causes  the  formation  of  a  fibrinous 
wall  around  it,  which  forms  a  cyst  with  fluid  contents.  In  other 
cases,  instead  of  the  formation  of  a  cyst,  there  is  proliferation  of 
connective  tissue  and  the  formation  of  a  pigmented  scar. 

Secondary  degenerations  follow,  due  to  the  cutting  off  of  nerve- 
fibres  from  their  parent  cells,  which  in  most  cases,  as  hemorrhage 
in  the  region  of  the  internal  capsule  is  very  common,  would  in- 
volve the  pyramidal  tract  and  be  the  cause  of  late  rigidity  and  in- 
creased reflexes  (the  inhibitory  influence  of  the  cortical  cells  being 
cut  off). 

Diagnosis. — The  history  of  an  apoplectic  stroke  with  conse- 
quent hemiplegia  is  the  important  point.  Embolic  apoplexy  is  to 
be  diagnosed  largely  by  history  of  cardiac  disease  and  in  the  finding 
of  a  well-marked  organic  heart  disease,  as  shown  by  murmur  over 
the  prfficordia.  In  embolic  apoplexy,  too,  there  is  not  so  constantly 
disturbance  of  consciousness,  and  the  sequent  paralysis  is  very 
apt  to  be  more  permanent  and  localized.  Following  the  embolic 
form  also,  careful  examination  may  reveal  alteration  in  the  phys- 
ical signs  of  the  existent  heart  disease;  for  instance,  the  murmur 
may  partially  disappear,  or  at  least  change  in  quality  very  mate- 
rially. In  tliromhosis  there  is  no  positive  way  of  telling,  except 
by  noting  previous  history  of  thrombosis  in  other  parts  of  the 
body  and  by  extensive  arterial  degeneration :  also  of  a  slow  onset. 

Prognosis. — About  50  per  cent  of  cases  of  apoplexy  recover 
from  the  attack;  75  per  cent  of  these  are  very  apt  to  have  re- 
currence; the  remainder  go  on  through  life  with  motor  paralysis 
of  the  parts  involved,  life  being  perhaps  curtailed,  on  an  average, 
by  a  decade.  The  expectancy  of  life  in  these  cases,  therefore,  is 
relatively  proportionate  to  the  heredity  of  longevity. 

Treatment  and  Nursing. — In  the  apoplectic  attack  the  patient 
should  be  guarded  very  carefully,  placed  in  the  supine  position, 


206  TEEATISE    ON    NEEVOUS    DISEASES 

with  the  head  partially  elevated;  ice-caps  should  be  placed  to  the 
head  and  hot-water  bottles  to  the  feet,  being  careful  not  to  burn 
the  patient,  since  obtunded  sensation  by  the  unconsciousness  would 
prevent  the  appreciation  of  heat.  Friction  to  the  lower  extremities 
will  aid  in  restoring  circulation  here,  and  thus  favour  the  relief  of 
congestion  in  the  brain;  or  a  mustard  bath  may  be  of  value.  A 
denture  or  other  foreign  body  should  be  carefully  sought  for,  since 
there  would  likely  be  strangulation  from  this  source.  It  may  be 
necessary  in  some  cases  to  produce  traction  on  the  tongue,  by  means 
of  a  handkerchief  or  an  artery  forceps  "  clipped "  on  to  the  tip 
of  the  organ.  Eespiration  can  also  be  aided  by  gentle,  firm  ele- 
vation of  the  larynx  with  the  tips  of  the  thumb  and  index-finger. 
The  inhalation  of  oxygen  is  a  method  I  have  nowhere  seen  used, 
but  it  is  scientifically  ideal  for  oxidation,  and  should  be  tried  in 
serious  cases  when  other  methods  have  failed.  The  revulsant  ac- 
tion through  the  intestinal  tract  should  be  brought  about  by  a 
hydragogue  cathartic.  For  this  purpose  croton  oil  is  employed  by 
the  physician,  2  to  4  drops  being  placed  upon  the  tongue  directly 
or  in  solution  upon  sugar.  The  reason  for  this  therapeutic  meas- 
ure is  that  the  congestion  of  the  mucous  membrane  causes  great 
exudation  of  serum  from  the  blood,  and  in  consequence  of  such 
local  and  general  depletion,  the  marked  relief  of  the  congestion  in 
the  brain.  Venesection  or  bleeding  by  leeches  are  important 
adjuncts  in  sthenic  cases.  At  the  end  of  forty-eight  hours  small 
quantities  of  milk  may  be  administered,  although  for  some  days 
there  should  never  be  excess  of  nutriment  placed  in  the  stomach. 
The  patient  should  be  kept  warm,  with  especial  attention  given, 
however,  to  ventilation.  Stimulants  should  be  eschewed  save  in 
the  use  of  strychnine,  which  may  be  prescribed  for  heart  failure 
only. 

In  the  "  getting  up  "  of  the  patient,  as  indicated  "before,  exer- 
cise should  be.  sparingly  indulged.  The  time  of  sitting  up  (not 
before  a  fortnight)  should  be  very  gradually  increased  from  day 
to  day  until  there  is  a  proper  adjustment  of  the  altered  and  ham- 
pered circulation.  A  patient  generally  has  to  employ  crutches  in 
his  first  endeavour  at  walking,  and  this  should  be  encouraged  until 
sufficient  power  has  been  regained,  when  the  crutches  can  be  substi- 
tuted by  a  cane.  When  contractures  occur  in  the  paral^^zed  ex- 
tremities, and  even  before  this  to  prevent  such  deformities,  it  is 
wise  to  employ  massage  and  stretching  in  the  affected  members. 


DISEASES    OF    THE    BEAIN    AND    MEMBEANES  307 

The  use  of  iodide  of  potash  is  the  most  valuable  remedy  at  our 
command  for  the  absorption  of  the  exudate  in  the  brain.  We 
have  seen  some  excellent  results  accomplished  with  this  drug,  espe- 
cially in  the  specific  cases  where  the  remedy  can  be  gradually 
pushed  up  to  several  hundred  grains  a  day.  Extra  exertion,  as  in 
lifting,  should  be  guarded  against,  the  bowels  must  be  kept  regu- 
lar, and  the  patient  should  live  a  life  much  less  active  than  usual. 
With  this  outline,  subjects  of  apoplexy  may  live  many  years  in 
fairly  comfortable  health,  although  hampered  considerably  as  to 
motion  and  mental  capacity. 

Cases  of  cardiac  disease  are  always  more  serious,  since  life  is 
menaced  by  the  fact  that  a  vegetation  may  be  carried  into  the  brain 
at  any  time. 

ENCEPHALITIS 

By  this  is  meant  an  inflammation  of  the  encephalon  or  brain 
mass. 

Causes. — The  causes  of  this  disease  are  injuries,  infectious  dis- 
eases and  local,  infections;  or  an  arterial  sclerosis,  by  cutting  off 
nutrition  to  the  cortex  of  the  brain. 

Varieties. — These  are  acute,  as  the  hemorrhagic;  and  second- 
ary or  chronic,  which  is  divided  into  the  septic  (or  brain  abscess) 
and  the  simple  chronic  encephalitis,  which  is  divided  into  enceph- 
alitis superior,  where  the  third  nuclei  are  affected,  and  enceplialitis 
inferior,  where  the  cranial  nerves  below  the  third  are  involved. 

Symptoms  of  Acute  Enceplialitis. — The  symptoms  of  acute 
hsemorrhagic  encephalitis  are  mental  confusion,  slight  rise  of  tem- 
perature, palsy  of  the  extremities  without  actual  paralysis,  and  but 
seldom  convulsions.  There  may  be  palsy  of  the  third  nerves.  The 
disease  is  very  rapid  in  onset,  and  may  be  accompanied  by  paraly- 
sis of  one  side  of  the  body  (hemiplegia). 

Prognosis. — This  is  bad,  the  disease  lasting  from  a  few  days 
to  a  week  or  even  ten  days,  the  patient  dying  of  pressure  upon  the 
brain  or  from  involvement  of  the  respiratory  or  cardiac  centres. 

Pathology.— This  consists  in  an  inflammation  of  the  cortical 
cells  of  the  brain  with  minute  haemorrhages  scattered  here  and 
there  throughout,  and  in  some  cases  a  distinct  hemorrhagic  effu- 
sion may  exist.  There  may  be  optic  neuritis,  but  seldom  choking 
of  the  disk. 


208  TREATISE    OX    XEEYOUS    DISEASES 

Symptoms  of  Chronic  Encephalitis. — S3^mptoms  of  chronic 
septic  encephalitis  are  all  the  above  symptoms  in  less  severity,  plus 
the  addition  of  chills  in  some  cases,  and  in  few  a  rise  of  tempera- 
ture, although  depression  of  temperature  is  frequent  even  in  cases 
of  abscess  of  the  brain.  There  is  usually  a  history  of  ear  disease  or 
chronic  nasal  disease  preceding  the  attack,  and  -with  this  history 
the  case  (giving  symptoms  of  inflammation  of  the  brain)  will  be 
found  to  be  of  septic  nature.  In  90  per  cent  of  all  cases  sepsis 
will  be  found. 

There  is  very  frequently  localization  of  the  inflammation  in 
septic  encephalitis,  although  there  may  be  multiple  foci  scattered 
throughout  the  encephalon;  if  local,  such  symptoms  as  convul- 
sions or  paralysis  may  be  set  up  by  the  irritation  or  destruction 
through  the  abscess.  Choked  disk  is  not  the  rule,  although  optic 
neuritis  is  likely  to  occur;  and  especially  is  this  the  case  if  the 
abscess  is  cerebellar  in  origin,  which  is  the  most  frequent  site  of 
abscesses,  because  chronic  middle-ear  disease  is  the  most  frequent 
cause  of  brain  abscess,  and  the  cerebellum  being  adjacent  to  the  ear 
would  explain  the  prevalence  in  this  locality.  If  the  abscess  is  in 
the  cerebellum,  the  cerebellar  gait  will  be  a  feature  in  the  diagno- 
sis; if  in  the  motor  area,  convulsions  and  paralysis  would  be 
looked  for;  if  in  the  spheno-temporal  lobe,  deafness  should  be 
looked  for;  or  if  in  the  posterior  parietal  lobe,  asteriognosis  and 
mind-blindness  may  be  a  part  of  the  symptomatology;  whereas  if 
located  in  the  frontal  lobe  there  are  no  special  symptoms,  the  men- 
tal stupor,  however,  being  profound. 

Diagnosis. — Differentiation  should  be  made  from  brain  tu- 
mour. This  is  done  by  the  history  of  the  case  and  the  development 
of  irregular  temperature  in  encephalitis  and  its  more  rapid 
progress. 

Prognosis. — The  growth  of  brain  abscess  is  usually  rapid,  the 
patient  dying  within  a  few  months  after  its  development.  It  may, 
however,  last  for  years,  and  become  incarcerated  and  form  a 
"  cold  "  abscess,  which  may  at  any  time,  from  trauma  especially, 
develop  sj'mptoms  of  acute  septic  encephalitis  and  result  in  death. 

Treatment. — This  is  surgical  alone.  If  a  case  is  diagnosed, 
the  surgeon  should  be  called  into  consultation  immediately  for 
decision  as  to  operation.  The  best  results  are  obtained  in  those 
that  are  cerebral  rather  than  cerebellar,  on  account  of  the  anatom- 
ical difficulties  in  the  latter. 


DISEASES    OF    THE    BRAIN    AXD    MEMBRANES  209 

The  symptoms  of  chronic  polio-encephalitis  superior  are  those 
of  simple  encephalitis  of  mild  type.  There  is  no  pain  connected 
with  the  disease,  and  the  third  nerve  being  involved,  we  have  in 
addition  ptosis,  exophthalmos,  and  iridoplegia.  The  eyes  are  also 
held  in  external  strabismus  if  the  sixth  nerve  is  still  intact. 

The  symptoms  of  polio-encephalitic  inferior  are  those  of  ordi- 
nary encephalitis,  plus  those  of  the  involvement  of  the  nuclei  of 
the  fourth  and  the  cranial  nerves  below  this.  If  the  pathetic  alone 
is  involved  there  would  be,  in  addition  to  the  above  symptoms, 
rotation  of  the  eyes  up  and  in.  There  is  an  absence  of  tempera- 
ture in  cases  of  chronic  nature.  According  to  the  nerves  involved 
below  the  fourth  nerve,  will  we  have  symptoms  of  paresis  of  those 
nerves. 

Prognosis  is  very  unfavourable.  Some  amelioration  may  be  ex- 
pected under  thorough  treatment. 

Diagnosis. — It  should  not  be  confused  or  confounded  with 
any  other  form  of  disease,  the  particular  point  being  preservation 
of  consciousness  with  the  incomplete  palsies  suggested  above. 

Treatment. — This  is  palliative;  quiet  is  essential;  apply  cold 
to  the  head,  and  use  supportive  measures,  such  as  strychnine  and 
belladonna  in  small  doses,  or  of  nitroglycerine,  to  support  the 
heart.  Iodides  should  be  used,  as  also  sorbefacients  where  there 
are  any  symptoms  indicating  exudates  about  the  inflammatory 
area.  Individual  galvanization  of  muscles  of  paralyzed  parts, 
such  as  of  the  eye  muscles,  may  be  of  some  value.  These  patients 
may  live  for  a  long  time — years;  however,  they  are  very  likely  to 
be  carried  off  by  an  intercurrent  affection,  as  pneumonia. 

BRAIN    TUMOUR    OR    CEREBRAL    NEOPLASM 

This  occurs  in  the  majority  of  instances  in  early  adult  life, 
depending  somewhat  on  the  nature  of  the  growth,  which  are  in 
the  order  given:  tuberculoma,  fibroma,  sarcoma,  glioma,  carcino- 
ma, and  gumma,  the  first  and  last  being  really  deposits  of  the  spe- 
cific granulomata.  The  tubercular  tumour  is  more  frequent  in 
childhood,  the  gumma  occurring  between  twenty  and  forty,  and 
sarcoma  at  about  thirty  years  of  age,  whereas  carcinoma  is  apt  to 
develop  after  forty  years  of  age. 

Brain  tumours  are  in  many  eases  distinctly  hereditary,  perhaps 
in  50  per  cent  of  the  cases.  This  fact  has  helped  the  writer  in 
14 


210  TREATISE   OX   XERVOUS   DISEASES 

the  diagnoses  of  obscure  cases,  Avhich,  put  with  the  weight  of  other 
evidence,  will  alwa3's  be  of  service. 

Symptoms. — These  are  of  two  kinds:  (1)  general,  and  (2)  spe- 
cial, local,  or  focal  symptoms. 

The  general  symptoms  consist  in  mental  excitement,  vomiting, 
so-called  reflex  or  cerebral  vomiting,  vertigo,  choked  disk  and 
headache,  the  latter  being  of  a  dull  character.  The  choked  disk  is 
present  in  between  90  to  95  per  cent  of  cases,  and  is  usually  more 
intense  in  cerebellar  lesion.  It  is  much  more  frequent  in  neoplasm 
than  in  other  organic  affections  within  the  cranium.  The  vomit- 
ing mentioned  comes  on  without  cause,  being  not  accompanied  by 
nausea,  nor  is  it  particularly  related  to  the  ingestion  of  food.  It 
is  designated  reflex  or  cerebral  or  central  vomiting. 

Special  local  or  focal  symptoms  are  of  importance  in  deter- 
mining the  location  of  the  growth.  If  it  be  located  in  the  frontal 
lobe,  there  will  very  likely  be  undue  mental  apathy,  unless  the  tu- 
mour itself  produces  much  irritation  or  protrudes  into  the  orbital 
cavities,  where,  of  course,  ordinary  methods  of  diagnosis  will  de- 
termine. The  peculiar  incoherency  of  mind  in  frontal-lobe  disease 
is  a  symptom,  if  taken  in  conjunction  with  other  signs  of  tumour, 
that  is  of  great  value.  Keen  has  laid  great  stress  upon  tenderness 
over  the  site  of  the  tumour.  This  is  of  value  only  in  cortical 
growths,  where  it  may  be  a  distinct  help. 

If  the  tumour  be  localized  in  the  motor  cortex  of  the  brain, 
there  will  be  convulsions,  focal  in  character,  due  to  the  location 
of  the  tumour,  and  later  in  its  growth  paralysis  of  the  same  parts 
will  follow. 

If  the  tumour  be  located  in  the  parietal  region,  sensory 
changes  may  be  found  associated  probably  with  mind-blindness  or 
asteriognosis,  depending  upon  the  location  of  the  growth. 

A  tumour  in  the  temporo-sphenoidal  lo"be  would  produce  word- 
deafness. 

A  tumour  in  Broca's  region  would  produce  motor  aphasia. 

A  tumour  located  in  the  corpus  striatum  would  produce  a  pare- 
sis of  the  opposite  side  without  convulsions,  and  likely  disturb- 
ances of  temperature,  due  to  the  involvement  of  the  centre  for  heat 
regulation  within  the  striatum. 

A  tnmour  in  the  optic  thalamus  would  produce  hemianopsia, 
and  within  the  anterior  part  the  Wernicke  pupillary  inaction  symp- 
tom; whereas,  if  posterior  to  the  thalamus,  the  centre  for  pupil 


DISEASES   OF   THE    BEAIX   AND   MEMBEAXES    211 

contraction  not  being  involved,  we  would  not  have  the  symptom 
present  accompanying  the  lateral  homonymous  hemianopsia.. 

A  tumour  in  the  corpus  callosum  will  produce  symptoms  simi- 
lar to  subcortical  tumours  from  which  they  cannot  be  distin- 
guished. 

A  tumour  in  the  cerebellum  produces  a  most  marked  choking 
of  the  disk,  is  typical,  and  in  addition  there  is  titubating  gait,  with 
other  evidences  of  ataxia,  frequently  manifested  in  the  hands,  as 
athetosis.  Knee-jerk  would  be  vacillating  and  early  increased. 
Later  it  may  disappear,  mostly  in  cases  involving  the  middle  lobe. 

Gyrus  Uncinatus. — Tumour  here  will  produce  perversion  of 
sense  of  smell — anosmia,  hyperosmia  if  involving  the  olfactory 
bulb  or  nerve. 

Gyrus  Fornicatus. — Tumour  in  this  region  will  be  evidenced 
by  a  loss  of  sense  of  smell. 

Cuneus. — Tumour  will  produce,  when  located  in  this  region, 
mind-blindness  and  hemianopsia  without  the  Wernicke  sign. 

Sensation  of  taste  may  be  disturbed  when  the  tumour  reaches 
the  centre  of  the  glosso-pharyngeal  and  facial  nerves  (chorda 
tympani). 

Tumours  of  the  meninges  will  cause  a  greater  amount  of  pain 
than  if  the  growths  develop  in  the  brain  structure,  since  the  sen- 
sory nerves  are  in  the  dura,  and  are  therefore  irritated. 

Pathology  of  Brain  Tumours. — This  will  entirely  depend  upon 
the  nature  of  the  growth,  whatever  that  may  be.  There  is  always 
found  about  the  neoplasm  a  subacute  inflammatory  process  with 
round-cell  infiltration  and  more  or  less  serous  exudate.  The  brain 
is  apt  to  become  oedematous  from  interference  with  the  circula- 
tion. These  points  should  be  particularly  remembered,  since  they 
give  rise  to  symptoms  which  are  necessary  in  the  diagnosis  of  the 
case.  In  a  case  of  Weir  Mitchell's,  the  localization  of  the  tumour 
was  confirmed  by  autopsy,  although  the  localizing  symptoms  were 
entirely  masked  in  the  later  course  of  the  affection  by  the  circula- 
tory disturbances  already  referred  to. 

Diagnosis. — This  is  a  difficult  matter  indeed.  The  principal 
disease  to  be  confused  with  it  is  abscess,  where  the  history  of 
septic  process  about  the  cranium  will  be  an  important  point  to 
be  taken  into  consideration.  The  excursion  of  temperature  above 
or  below  normal  will  also  assist  in  the  diagnosis.  Chronic  men- 
ingitis and  sinusitis  from  the  pain  alone  are  likely  to  be  confused 


^13  TEEATISE    01^   :N^ERV0ITS   DISEASES 

with  tumour,  but  are  wanting  in  localizing  symptoms,  and  in  the 
intensity  of  the  choked  disk  seen  in  tumour. 

Prognosis. — This  is  bad,  biit  7  per  cent  of  the  cases  are  oper- 
able, and  just  this  per  cent  has  a  chance  of  recovery. 

Treatment.- — Beyond  surgical  there  is  little  to  be  done;  med- 
ical treatment  is  simply  palliative,  such  as  in  the  use  of  iodides, 
mercury,  or  other  alteratives.  Hygienic  guarding  of  the  patient 
is  essential  above  that  of  all  other  brain  affections.  Pain  must  be 
controlled  by  morphia.  A  pill  of  camphor  monobromate,  gr.  iij, 
often  affords  relief. 


CHAPTER    XII 

INFLAMMATIONS  OF  THE  MEMBRANES  OF  THE  CORD 
AND   UNCLASSIFIED  DISEASES 

External  pachymeningitis  involving  the  dura  mater ;  internal  meningitis  in- 
volving the  dura  mater ;  leptomeningitis  involving  the  pia  mater ;  hyper- 
trophic pachymeningitis  involving  both  dura  and  pia. 

Inflammations  of  the  Dura  (Pachymeningitis). — a.  Pachymen- 
ingitis externa  is  a  secondary  inflammation,  but  is  occasionally 
met  in  the  acute  form  following  caries,  tumours,  aneurysms,  or 
syphilitic  affections  of  bones.  An  abscess  may  penetrate  the  spi- 
nal cord,  or  the  inflammation  may  be  set  up  in  the  peridural 
tissue  in  long-standing  cases  of  decubitus,  pachymeningitis  re- 
sulting. 

Symptoms. — These  are  usually  those  of  compression  myelitis. 
The  chronic  form  of  external  pachymeningitis  is  most  commonly 
secondary  to  tuberculous  disease  of  the  spine  (see  Myelitis  in 
Pott's  Disease,  Chapter  XJ ;  hence  the  vertebral  disease  is  impor- 
tant in  the  production  of  symptoms.  This  form  is  apt  to  be  local- 
ized to  the  site  of  Pott's  disease.  The  internal  surface  of  the 
dura  may  be  perfectly  smooth  and  in  some  cases  but  slightly  ad- 
herent to  the  arachnoid.  The  external  surface  is  rough  and  cov- 
ered with  a  cheesy  substance.  In  some  cases  this  material  is 
chiefly  anterior  to,  and  in  other  cases  it  completely  surrounds  the 
cord. 

h.  Pachymeningitis  interna  is  usually  found  located  in  the  cer- 
vical region.  The  space  between  the  cord  and  the  dura  is  occu- 
pied by  a  form  of  concentrically  arranged  fibres,  developing  within 
the  dura,  and  not  on  the  outside  at  all.  The  condition  is  similar 
to  ha?morrhagic  paeliymeningitis  interna  of  the  brain.  The  cord 
is  usually  compressed,  the  central  canal  dilated  (hydromyelus), 
and  there  are  secondary  degenerations.     The  nerve-roots  are  in- 

213 


214 


TREATISE    OX    XervOUS    DISEASES 


volved  in  the  growths  and  are  damaged  and  compressed.     The 
disease  is  chronic  and  may  he  limited  to  one  segment,  or  in  the 

greater  number  of  cases 
it  actually  involves  a  con- 
siderable portion  of  the 
cervical  enlargement. 

Symptoms.  —  Intense 
pains  along  the  nerves 
whose  roots  are  involved 
are  present.  There  may 
be  hypersesthesia  or  anaes- 
thesia with  numbness  and 
atrophy  of  the  interossei, 
hypothenar  and  thenar 
groups.  The  arms  be- 
come weak;,  the  extensors 
may  remain  intact  while 
the  flexors  are  affected, 
producing  the  so-called 
"  claw-hand  "  —  main  en 
grijfe.  At  times  the  sec- 
ond stage  also,  of  the 
French,-  consisting  of  in- 
volvement of  the  lower  ex- 
tremities and  introduction 
of  spastic  paralysis,  may 
>upervene  several  months 
later,  due  to  secondary  de- 
generation in  the  cord. 
The  disease  runs  a  chronic 
course,  lasting  two  or  more 
5'ears.  In  a  few  instances 
in  which  symptoms  point- 
ed definitely  to  this  condi- 
tion recovery  took  place, 
and  I  have  no  doubt  that  not  a  few  cases  of  amyotrophic  lateral 
sclerosis  that  have  been  reported  much  improved  by  several  observ- 
ers are  cases  of  pachymeningitis  interna  with  complete  absorption 
of  exudate. 

Diagnosis. — (a)   The  external  form  is  diagnosed  by  the  con- 


FiG.  5:3.— Chronic  Cervical  Tubercular 
External  Pachymeningitis.  (Specimen 
from  case  of  complete  diplegia  in  the  Phila- 
delphia Hospital.) 

(o)  Site  of  tubercular  deposit  at  site  of  kyphosis ; 
(0)  Cauda. 


IXFLAMMATIOX    OF    MEMBRANES    OF    COED     215 

currence  of  Pott's  disease,  the  absence  of  atrophy  of  muscles, 
and  the  usual  seat  being  in  the  dorso-lumbar  region  of  the  cord. 
(&)  The  internal  type  is  diagnosed  first  from  amyotrophic  lat- 
eral sclerosis  by  the  fact  that  severe  pain  does  not  occur  in  the 
latter ;  from  syringomyelia  by  the  absence  of  sensory  changes  char- 
acteristic of  gliosis ;  and  from  tumours  by  the  more  localized  symp- 
toms in  neoplasm. 

Prognosis. — This  is  to  be  guarded,  since  some  of  the  most 
marked  cases  have  been  greatly  improved  to  the  surprise  of  the 
neurologist.  Given  a  case  in  which  the  disease  has  been  stayed 
with  physical  health  of  the  patient  maintained,  and  vs^here  great 
contractures  or  atrophy  of  the  part  has  not  occurred,  the  prog- 
nosis may  be  guardedly  given  as  favourable  to  partial  restoration 
of  the  health,  at  least.  Acute  fulminating  cases  from  the  begin- 
ning usually  end  in  the  death  of  the  patient.  Even  in  cases  that 
have  apparently  recovered  any  undue  exertion  or  exposure  to  heat 
is  apt  to  cause  recrudescence.  Treatment  of  either  form  is  the 
same  as  for  that  of  other  types  of  meningeal  inflammation. 

LEPTOMENINGITIS 

This  is  a  condition  closely  allied  to  pachymeningitis  physio- 
logically, although  pathologically  pachymeningitis  consists  of  in- 
flammation of  the  pia.  Practically  these  inflammations  are  asso- 
ciated more  or  less  in  every  case.  Leptomeningitis  is  more  likely 
to  be  acute  or  fulminating,  due  to  the  fact  that  it  is,  as  a  rule, 
a  septic  type  of  inflammation,  and  also  is  resident  in  the  larger 
blood-vessels  of  the  pia  associated  more  intimately  with  the  nerv- 
ous system.  For  this  reason,  even  although  the  inflammation  be 
not  so  severe,  serious  symptoms  would  result.  The  difference  in 
the  symptomatology  between  leptomeningitis  and  pachymenin- 
gitis would  consist  largely  in  the  fulminating  character  of  the  for- 
mer, accompanied  by  much  less  pain  in  the  back  or  over  the  site  of 
inflammation,  for  the  reason  that  the  sensory  roots  are  less  im- 
pinged upon;  but  there  is  greater  parah'sis  in  the  parts  below 
site  of  lesion,  and  also  the  greater  liability  to  decubitus.  Lepto- 
meningitis is  seldom  a  chronic  disease,  hence  there  are  no  special 
symptoms  described  for  the  latter,  since  that  would  be  clinically 
the  same  in  all  respects  as  pachymeningitis  chronica. 

Prognosis. — This  is  uncertain.    It  will  depend  largely  upon  the 


216  TKEATISE    OK    NERVOUS    DISEASES 

degree  of  infection  and  the  extent  of  involvement  of  the  cord. 
Where  there  is  early  involvement  of  the  multipolar  nerve-cells 
there  is  usually  decubitus^  accompanied  by  great  palsy  and  disturb- 
ance of  the  bladder  as  well  as  of  the  rectum,  the  patient  usually 
succumbing  within  a  few  days.  Such  cases  rarely  recover  without 
chronic  myelitis  and  paraplegia  being  the  result  of  the  leptomen- 
ingitis. 


Fig  .54. — Atrophy  of  Interossei,  Thenar  and  Hypothenar  Muscles  of  Both 
Hands;  (also  of  Shoulder  Girdle  and  Pectoral  Muscles)  in  a  case  of 
Infectious  Pachymeningitis  Cervicalis  Hypertrophica.  (Medico-Chirur- 
gical  Hospital.) 

Hypertrophic  packymeiimgitis  involves  both  pia  and  dura. 
It  is  usually  septic  in  origin.  The  gonococcus  may  be  the  organ- 
ism acting  as  exciting  cause,  as  in  the  case  under  our  care  shown 
in  the  illustration  (iFig.  54). 

Treatment  of  Pachymeningitis  and  Leptomeningitis. — This 
consists  of  absolute  rest  in  bed  in  a  quiet,  darkened  room,  the  appli- 
cation of  ice  to  the  spine,  and  the  use  of  counter-irritants,  such  as 


UNCLASSIFIED    DISEASES  217 

strong  tincture  of  iodine  over  the  site  of  the  inflammation,  of  blis- 
ters, or  the  actual  cautery,  repeatedly  applied,  in  chronic  cases.  In 
the  acute  form  general  antiphlogistic  measures  may  be  necessary, 
such  as  cold  sponging  or  the  cold  pack ;  or  by  antipyretic  drugs  cau- 
tiously used,  such  as  phenacetine  and  antipyrine.  It  may  be  neces- 
sary to  give  small  doses  of  morphine  to  control  the  pain.  If  there 
are  convulsions,  the  use  of  bromides  and  chloral,  mixed,  in  fairly 
large  doses,  will  be  indicated.  A  15-per-cent  ointment  of  soluble 
metallic  silver  used  by  inunction  in  dram  doses  is  a  valuable  rem- 
edy in  septic  cases.  In  chronic  cases,  if  convulsions  persist,  admin- 
ister ether  for  their  control.  If  contractures  follow,  orthopaedic 
treatment  may  be  necessary,  such  as  tenotomy,  or  extension  of  tire 
contracted  limbs.  This,  of  course,  should  be  resorted  to  after  it 
is  evident  that  massage  and  Swedish  movements  prove  of  no  avail. 
The  use  of  potassium  iodide  is  valuable  as  a  remedy  in  chronic 
cases  for  the  absorption  of  the  exudate.  This  drug  should  be 
pushed  to  its  physiological  limit  and  continued  for  many  weeks. 
In  cases  of  paraplegia,  resulting  from  pressure  of  exudate  or 
actual  inflammation  through  extension  from  the  pia  to  the  cord, 
the  treatment  will  be  that  of  the  existent  sequent  myelitis. 


CAISSON    DISEASE 

Synonym:   Diver's  disease 

This  is  a  disease  with  marked  nervous  manifestations,  induced 
by  the  long  submergence  of  the  body  in  air  at  high  pressure.  It  is 
doubtful  if  the  affection  would  develop,  until  very  late  at  least, 
were  the  body  kept  in  a  gradually  increased  atmospheric  pressure. 

Etiology. — As  indicated  above,  the  affection  is  caused  by  the 
sudden  change  from  increased  to  decreased  pressure  of  the  atmos- 
phere. It  is  probably  due  to  the  enfeebled  vaso-motor  nervous  sys- 
tem. Divers  are  particularly  subject  to  this,  hence  the  name  of 
diver's  paralysis.  The  pressure  that  will  induce  diver's  paralysis 
must  be  more  than  three  atmospheres. 

Symptoms. — It  is  characterized  by  a  paraplegia,  less  frequently 
general  palsy,  appearing  on  returning  from  the  compressed  to  the 
surface  atmospheric  pressure.  These  symptoms  are  more  likely 
to  develop  on  rapid  change  from  the  high  to  the  ordinary  atmos- 
pheric pressure.     They  may  supervene  shortly  after  leaving  the 


218  TREATISE    ON    NERVOUS    DISEASES 

caisson  or  may  be  several  hours  in  their  development.  In  the 
mildest  forms  there  are  pains  about  the  knees,  which  are  often  of 
great  severity.  Abdominal  pain  and  vomiting  are  not  uncommon. 
The  muscles  may  be  tender  to  the  touch  and  the  patient  walk  in  a 
spastic  fashion.  Accompanying  the  other  neurologic  symptoms 
there  is  dizziness  and  intense  headache,  which  later  may,  however, 
occur  without  vertigo.  In  the  severer  forms  we  may  find  com- 
plete motor  and  sensory  paraplegia,  a  monoplegia  or  hemiplegia 
being  rare.  The  most  extreme  attacks  resemble  apoplexy;  pro- 
found coma,  and  death,  rapidly  supervenes  within  a  few  hours. 

Prognosis. — In  cases  of  paraplegia  the  outlook  is  usually  good. 
The  palsy  may  pass  off  within  a  day  or  may  continue  for  several 
months. 

Pathology. — This  is  indefinite,  although  it  is  probably  a 
vaso-motor  disturbance  in  the  simple  cases  that  recover.  In  the 
severer  cases  there  have  been  found,  as  in  the  case  of  Ley  den, 
foci  of  haemorrhages  and  evidence  of  acute  myelitis.  Fissuring  of 
the  cord  sometimes  occurs,  some  authorities  believing  it  to  be  a 
constant  phenomenon.  It  has  been  suggested  that  this  condition  is 
due  to  the  freeing  of  nitrogen  within  the  cord,  the  element  having 
been  absorbed  by  the  blood  under  high  pressure. 

Treatment. — The  patient  should  be  kept  quiet.  Pain  must 
be  controlled  by  analgesics,  such  as  morphine,  etc.  Inhalations 
of  oxygen  and  the  use  of  compressed  air  has  been  advised.  Paral- 
ysis should  be  treated  as  any  other  form  of  palsy  of  similar  type. 
As  a  prophylactic  measure  divers  should  pass  gradually  into  the 
compressed-air  chamber.  According  to  A.  H.  Smith,  at  least  five 
minutes  should  be  allowed  for  each  additional  atmospheric  pres- 
sure. Another  prophylactic  measure  consists  in  bringing  the 
patient  very  slowly  into  the  normal  atmosphere;  as  we  have  indi- 
cated should  be  the  case  in  entering  the  compressed-air  chamber. 
Ergot  is  a  remedy  which  may  control  the  vaso-motor  nerves  in 
cases  where  there  is  paralysis  of  vaso-constrictors.  It  should  be 
given  hypodermically  in  half-dram  doses.  Bandaging  of  the  limbs 
has  also  been  advised. 


UNCLASSIFIED    DISEASES  219 

LANDRY'S    DISEASE   (ACUTE    ASCENDING 
PARALYSIS) 

This  is  a  disease  probably  of  toxic  nature,  more  frequent  in 
males,  and  coming  on  in  cool  weather  in  the  greater  number  of 
cases,  as  though  the  temperature  had  something  to  do  with  its  pro- 
duction.   It  is  in  all  probability  due  to  an  autocthonous  poison. 

Symptoms. — A  case  of  Landry's  disease,  or  ascending  palsy, 
if  it  be  typical,  consists  of  a  fulminating  onset  of  paralysis,  begin- 
ning in  the  lower  extremities,  and  ascending  rapidly  to  the  trunk 
and  upper  extremities,  the  head  muscles  escaping.  It  usually 
occurs  between  twenty  and  thirty  years  of  age.  The  symptoms  are 
frequently  preceded  by  moderately  high  temperature.  Nausea 
occurs,  but  gastro-intestinal  disturbance  is  not  a  particularly  nota- 
ble feature  of  the  disease.  There  is  a  sense  of  parsesthesia,  to  a 
slight  degree  only,  in  the  extremities,  but  no  other  distinct  sen- 
sory disturbances.  While  the  reflexes  are  absent  there  is  no  ten- 
derness of  nerve-trunks  and  no  involvement  of  the  sphincters  of 
the  bladder  or  of  the  rectum.  The  patient  is  almost  completely 
paralyzed,  as  above  described,  within  seventy-two  hours  after  the 
onset  of  the  disease,  and  may  not  be  able  to  move  a  muscle  below 
the  head;  the  chest  expansion  being  very  little,  cardiac  rhythm 
irregular,  sometimes  very  rapid  (tachycardia)  ;  the  respiration 
being  carried  on  entirely  by  the  diaphragm  through  the  phrenic 
nerves.  The  external  respiratory  nerve  coming  off  lower  down 
from  the  cord  being  affected,  leaves  the  motor  function  of  respira- 
tion alone  to  the  phrenic  nerve.  Involvement  of  the  pneumogas- 
tric  nerve  frequently  occurs,  which  is  another  serious  cause  of  em- 
barrassed respiration,  heart  action,  and  cord  function.  This  is 
often  the  cause  of  the  sudden  death  which  usually  supervenes  at 
the  end  of  a  week  or  ten  days.  There  have  been  no  cases  recorded, 
such  as  those  described,  that  recovered  without  leaving  some  dis- 
turbance or  serious  alteration  of  the  nervous  system  as  a  sequelae. 
A  case  under  the  writer's  care  may  be  referred  to,  where  the  man 
is  to-day  the  subject  of  chronic  muscular  atrophy  with  main  en 
griffe  or  claw-hand.  So  that  cases  that  do  recover  are  generally 
those  where  the  symptoms  will  have  been  proved  to  be  the  result  of 
some  definite  lesion,  and  not  those  in  which  the  pathology  has  not 
as  yet  been  understood  or  discovered.  In  some  instances  the 
paralysis  may  be  descending  in  its  initiation  and  sequent  course. 


220  TREATISE    OX    NERVOUS    DISEASES 

Diagnosis  is  therefore  as  between  this  disease  and  multiple 
neuritis,  if  any  difference  at  all  exists,  the  only  point  being  that 
the  cases  that  have  recovered  present  signs  of  multiple  neuritis  or 
involvement  of  the  cord.  The  fatal  cas6s,  through  the  rapidity 
of  their  courses,  do  not  develop  pathologic  changes  that  are  demon- 
strable by  modern  microscopic  technique. 

Prognosis. — This  should  be  put  down  as  absolutely  fatal. 

Pathology. — In  some  cases  diffuse  nwelitis  or  neuritis  has 
been  found.  In  others,  the  majority,  no  lesion  has  been  detected. 
In  one  reported  by  the  writer  (Journal  of  Nervous  and  Mental 
Diseases,  January,  1893),  a  multiple  neuritis  is  the  real  cause  of 
the  clinical  picture.  Of  course,  these  cases  are  taken  out  of  the 
realm  of  Landry's  palsy  per  se,  but  the  clinical  picture  may  be 
identical.  A  typical  ease  of  Landry's  palsy  consists  of  no  definite 
lesion;  nor  does  the  patient  develop  trophic  changes,  such  as  bed- 
sores. 

Treatment. — This  consists  in  supporting  the  patient  by  means 
of  strvchnine  hypodermically,  or  by  transfusion  of  blood  by  hypo- 
dermoclvsis  of  normal  salt  solution,  in  order  to  counteract  the  con- 
dition of  the  blood,  which  is  undoubtedly  toxic.  The  use  of 
galvanism  to  encourage  respiration  and  cardiac  tone  would  be  of 
importance  in  the  cases  where  these  fimctions  are  particularly 
hampered.  Rectal  nourishment  is  a  procedure  which  will  be  of 
value,  since  any  attempt  to  give  food  per  or  em  might  excite  dan- 
gerous symptoms  of  respiratory  or  cardiac  failure.  If  the  case 
should  survive,  the  after-treatment  would  be  as  indicated  in 
chronic  neuritis  or  m3^elitis— i.  e.,  massage,  galvanism,  alterative 
drugs,  as  iodide  of  potassium  or  the  so-called  Donovan's  solution, 
the  liquor  arsenii  et  hydrargyri  iodidi  (a  1-per-cent  solution), 
given  in  3-  to  5-minim  doses  thrice  daily.  We  know  of  no  better 
alterative  remedy  in  chronic  non-specific  inflammatory  states  than 
this  drug.  The  use  of  crutches  may  be  necessary  to  get  the  patient 
about.  In  all  chronic  palsies  we  wish  to  again  urge  getting  the 
patient  into  action  soon,  since  use  stimulates  function ;  otherwise 
hysteria  may  soon  become  a  part  of  the  clinical  picture. 


CHAPTEE    XIII 
DISEASES  OF  TEE  SPINAL   CORD 

MALFORMATIONS    OF  THE  SPINAL  CORD— SYSTEM 

DISEASES 

{General  considerations) 

Theee  are  some  thirty  diseases  of  the  spinal  cord.  The  ma- 
jority are  organic  and  come  under  the  head  of  inflammations  and 
of  degenerations  or  system  diseases.  Organic  diseases  the  result 
of  injury  and  inflammations  are  most  common.  Functional  dis- 
eases of  the  cord  alone  are  rare,  such  as  the  so-called  "  irritable 
spine/'  which  latter,  too,  is  associated  with  general  functional  dis- 
eases, as  hysteria. 

Etiology. — Most  causes  come  under  injur}',  auto-intoxications, 
poisons  from  without,  exposure,  infectious  diseases,  and  excess 
of  functionation.  Middle-aged  persons  are  more  liable  to  these 
affections.  Heredity  may  play  a  part  in  the  predisposition  due  to 
vulnerable  nerve-tissue. 

Symptoms. — These  all  come  under  the  head  of  irritation,  de- 
pression, and  of  perversion.  Irritative  symptoms  consist  of  pains, 
paraesthesias,  hyperassthesias,  and  feelings  of  constriction  around 
the  waist,  rigidity,  spasms,  exaggerated  reflexes,  and  irritability 
of  the  visceral  and  vascular  functions.  The  symptoms  of  de- 
pression are  those  of  anaesthesia,  ataxia,  palsies,  wasting,  and 
loss  of  control  of  viscera,  as  of  the  bladder.  In  cord  disease  para- 
plegia is  the  common  form  of  palsy.  S}Tnptoms  of  irritability 
and  depression  often  accompany  each  other.  The  more  super- 
ficial, the  more  irritative  signs  exist;  the  more  central,  the  more 
paralysis  and  visceral  weakness  prevail.  In  meningitis  and  men- 
ingeal affections  there  is  much  pain,  and  vice  versa,  as  to  cord 
diseases  j^er  se. 

Pathology. — Inflammation  of  the  cord  membranes  is  not  un- 
common; ])ut  primary  inflammation  of  the  cord  itself  is  unusual, 
>  221 


32a  TREATISE    ON   NERVOUS    DISEASES 

since  most  of  the  diseases  that  used  to  be  called  myelitis  are  sec- 
ondary to  injuries  and  softenings.  Tabes  and  progressive  muscu- 
lar atrophy  are  given  as  "  system  diseases  "  by  most  writers,  be- 
cause they  affect  certain  long-fibre  tracts  or  groups  of  cells;  but 
this  name  implies  too  many  restrictions,  hence  it  is  retained  only 
as  a  matter  of  convenience.  Secondary  degenerations  alone  are  sys- 
temic. The  cord  is  not  infrequently  the  seat  of  abscesses,  haemor- 
rhages, or  tumours. 

Diagnosis. — In  making  a  diagnosis  of  cord  diseases  help  comes 
through  a  thorough  knowledge  of  cord  functions.  Physiology  land 
anatomy  point  out  the  signs  and  symptoms  more  clearly  than  in 
any  other  part  of  the  body.     (See  Chapter  I.) 

Prognosis. — Spinal-cord  tissue  once  destroyed  can  never  be 
renewed  to  more  than  a  very  limited  extent.  This  regeneration 
applies  to  the  nerve-fibres,  jiot  the  cells.  The  diseased  cord  fre- 
quently adjusts  itself  to  the  pathological  damage;  but  again,  in- 
jury is  very  likely  to  extend  by  the  process  of  secondary  degen- 
eration so  rapidly  that  compensatory  function  cannot  take  place. 

The  special  diseases  of  the  cord  are  as  follows: 

(1)  Malformations:  Myocele,  meningo-myelocele  (spina 
bifida),  meningocele,  heteropia,  amyelia,  micromyelia,  macromy- 
elia,  double  cord. 

(2)  Vascular  disorders:  Ansemia,  hypersemia,  haemorrhage, 
endarteritis  with  aneurysm,  embolism,  thrombosis,  oedema.  Sec- 
ondary to  these  conditions  are  softenings,  myelomalacia,  and  scle- 
rosis. 

(3)  Inftmnmations :  Meningitis,  myelitis,  abscess.  Also  sec- 
ondary softening  and  sclerosis. 

(4)  Degenerations:  Primary:  Locomotor  ataxia,  combined 
scleroses,  hereditary  scleroses,  progressive  muscular  atrophy,  and 
similar  affections. 

(5)  Syphilis:  Meningo-myelitis,  gumma,  single  or  multiple, 
and  specific  endarteritis. 

(6)  Tuberculosis:  Miliary  and  solitary. 

(7)  Tumours. 

(8)  Functional  and  toxic  disorders. 


DISEASES    OF    THE    SPINAL    COED  223 

MALFORMATIONS 

Spitia  Bifida  {Rhachischisis  Posterior) 

This  is  a  congenital  hernia  of  the  spinal  membranes^  sometimes 
of  the  cord,  through  a  cleft  in  the  vertebra  caused  by  absence  of 
the  vertebral  arches.  It  is  therefore  more  of  a  malformation  of 
the  vertebral  canal  rather  than  of  the  cord,  although  this  is  not 
always  so,  for  the  cord  and  its  membranes  may  be  found  in  a  con- 
dition of  agenesis  at  the  site  of  canal  malformation. 

Etiology. — About  1  in  1,200  children  are  thus  affected  (French 
statistics).  It  may  be  associated "  with  hydrocephalus  or  with 
some  other  defect  of  development,  such  as  imperforate  anus  or 
pharynx,  or  of  ventral  hernia.  Heredity  may  be  a  factor  in  its 
causation.  It  is  not  due  to  dropsy  of  the  cord,  but  is  a  true 
malformation.     It  is  more  common  in  males. 

Varieties. — There  are  three  forms  described: 

(1)  Spinal  meningocele  is  a  condition  in  which  the  spinal 
membranes  alone  protrude  into  the  sac. 

(2)  Spinal  meningo-myelocele  is  a  form  in  which  the  mem- 
branes and  cord  both  pass  into  the  sac. 

(3)  S3'ringo-myelocele  (hydrorhachis- interna)  is  a  form  in 
which  the  fluid  is  in  the  central  spinal  canal  and  the  inner  lining 
of  the  sac  is  formed  by  the  meninges  and  thinned-out  spinal  cord. 

Anatomy. — The  most  common  are  the  first  two  types,  wliich 
are  called  hydrorhachis  externa.  The  fluid  lies  in  the  subarach- 
noid space,  hence  the  wall  of  the  protruding  cyst  is  lined  with  the 
dura  and  arachnoid.  The  nerves  and  cord  protrude  into  the  sac 
in  two  thirds  of  the  cases,  forming  a  meningo-myelocele,  but  in 
some  only  a  few  nerves  are  found.  When  protruding  into  the 
sac  they  lie  on  the  posterior  and  median  surface,  being  attached 
and  forming  part  of  the  wall;  hence  the  spinal  nerves  start  from 
the  wall  of  the  sac  and  go  back  into  the  vertebral  canal.  Be- 
sides the  above-noted  contents  the  tumour  contains  fat  and  con- 
nective tissue.  The  external  surface  is  often  red,  flattened  out, 
and  smooth,  and  there  is  sometimes  a  depression  on  its  median 
surface  where  the  cord  is  attached. 

Symptoms. — Spina  bifida  generally  occurs  in  the  lumbar  and 
sacral  regions,  since  the  laminas  here  are  the  last  to  solidify.  But 
two  or  three  vertebrge  are  usually  involved.  The  tumour  varies 
from  1  inch  to  6  or  7  inches  in  diameter.     It  may  be  sessile  or 


224  TEEATISE    ON    NEEVOUS    DISEASES 

be  pedunculated.  The  outer  skin  is  often  glossy,  or  tough,  thick- 
ened, or  ulcerated. 

Children  with  spina  bifida  are  usually  very  poorly  nourished 
or  inherently  feeble,  and  as  a  rule  poorly  developed  mentally.  In 
over  50  per  cent  of  the  cases  paraplegia  is  found  associated  more 
or  less  with  ansesthesia  or  involvement  of  the  sphincter  muscles. 
Contractions  and  contractures  may  occur,  causing  various  phases 
of  acquired  talipes. 

Prognosis  is  grave,  being  best  for  meningocele.  The  patient 
may  live  in  such  cases  to  early  adult  life,  but  injury  or  infection 
may  occur,  and  the  patient  be  carried  off  by  secondary  myelitis. 

Diagnosis  is  fairly  certain.  Usually  it  is  only  necessary  to 
exclude  congenital  tumours  which  happen  to  be  located  in  the 
lumbo-sacral  region.  •  The  most  important  question  to  decide  is 
w^hether  the  cord  and  nerves  are  present  in  the  sac,  which  is 
very  probable  if  there  is  much  paralysis,  ansesthesia,  or  sphinc- 
ter trouble,  or  if  there  is  a  depression  on  the  median  external 
surface.  The  passing  of  an  aseptic  insulated  needle  connected 
with  a  galvanic  battery  may  be  tried  in  a  difficult  case. 

Treatment  is  entirely  surgical,  and  of  •  avail  only  in  menin- 
gocele. At  present  injections  of  Morton's  fluid  (iodine,  gr.  x; 
potas.  iodid.,  gr.  xxx;  gh^cerin,  §j),  in  dram  doses,  seem  to  be 
the  most  successful.  These  injections  should  be  made  on  the 
outer  portion  of  the  sac,  the  child  being  kept  on  the  back.  Com- 
pression is  dangerous  if  the  fluid  has  been  previously  withdrawn. 
Opening  the  sac,  excising,  or  ligaturing  are  most  dangerous, 
especially  if  part  of  the  cord  should  happen  to  be  in  the  sac.  In 
skilled  hands  surgical  results  have  recently  been  more  favour- 
able. Operation  should  not  be  done  within  the  first  four  months 
of  life. 

MENINGOCELE  OF  THE  CORD 

Meningocele  of  the  cord  is  protrusion  of  some  or  a  portion  of 
the  membranes  of  the  cord  from  the  canal.  It  usually  occurs  in 
the  infant,  being  a  congenital  defect  of  closure  of  the  neural  canal, 
the  bones  and  membranes  themselves  being  involved.  In  some 
cases  the  cord  itself  protrudes. 

Symptoms. — 'No  symptoms  exist  except  the  physical  signs  of 
protrusion  of  the  tumour  (which  is  usually  in  the  lower  lumbar, 
or  in  the  sacral  region  of  the  cord)  until  at  some  later  period  in 


DISEASES    OF    THE    SPINAL    COED 


335 


life  injury  to  tiiis  mass  sets  up  an  inflammation,  when  the  symp- 
toms of  spinal  meningitis  and  paraplegia  will  follow.  The  worst 
cases,  due  to  the  defect  of  the  nervous  system  as  well,  will  pre- 
sent typical  signs  and  symptoms  of  paraplegia,  with  contractures, 
loss  of  sensation,  involvement  of  the  sphincters,  bedsores,  etc. 

Prognosis. — This  will  depend  upon  the  degree  of  defect  and 
the  condition  of  the  patient.  More  cases  may  pass  through  life 
undisturbed,  but  the  existence  of  a  tumour  about  the  sacral  re- 


FiG.  55.— Agenesis  and  Micromtelia.  of  Spinal  Cord  in  a  Male  aged  Forty 
Years  ;  also  Lack  of  Development  of  the  Acoustic  Nervous  Centres. 
(Philadelphia  Hospital. ) 

gion  is  always  a  menace  to  life.  Cases  with  paraplegia  at  birth 
will  be  very  apt  to  succumb  within  a  few  months  to  a  year. 

Treatment. — As  in  cases  of  spinal  meningocele,  treatment 
would  be  mainly  surgical,  if  at  all.  This  consists  in  compression 
and  protection  of  the  part.  Removing  the  protruding  mass,  or  the 
injection  of  carbolic  acid  or  some  other  irritant  into  the  tumour 
mass,  with  the  hope  of  causing  its  disappearance,  should  of  course 
only  be  done  in  selected  cases. 

Heteropia  is  a  rare  malformation  wherein  masses  oi  gray  mat- 
ter are  found  in  abnormal  positions.  Van  Gieson  describes  a  false 
heteropia  that  may  be  caused  by  manipulation  of  the  cord  after 
death,  in  which  case  the  displaced  masses  consist  of  nerve-cells 
or  neuroglia. 

Amyelia,  or  absence  of  the  spinal  cord,  can  exist  only  when 
15 


22G  TREATISE    OX    XEETOUS    DISEASES 

the  brain  is  absent^  although  absence  of  the  brain  may  occur 
without  absence  of  the  cord.  In  amyelia  Ihe  spinal  nerves  are  usu- 
ally present.    Amyelic  monsters  cannot  live. 

Double  cord  is  very  rare,  and  involves  only  a  part  of  the  cord 
except  in  cases  where  there  is  a  double  vertebral  canal. 

Double  central  canal  is  not  rare.  It  usually  is  found  in  only 
a  part  of  the  cord,  and  the  two  canals  lie  parallel. 

Asymmetry  of  the  cord,  usually  due  to  abnormality  in  the 
course  of  the  pyramidal  tracts,  is  not  so  rare. 

Splitting  of  the  cord  and  defects  in  development  at  special 
levels  are  found  occasionally. 

Agenesis  implies  lack  of  proper  development  of  the  cord.  (Eig. 
55.) 

Micromyelia  is  a  condition  in  which  the  cord  is  abnormally 
short  or  is  small  in  size.  The  normal  cord  varies  in  diameter 
from  6  to  9  millimetres  (dorsal),  8  to  11  millimetres  (upper 
cervical).  15  millimetres  (cervical),  and  12  millimetres  (lumbar). 

SYSTEM   DISEASES 

By  reference  to  the  chapter  on  i\.natomy  will  be  found  the 
division  of  the  spinal  cord  into  certain  tracts  or  systems.  A 
degenerative  disease  of  these  tracts  is  frequently  confined  to  one 
or  may  extend  to  two  tracts.  The  first  is  designated  a  simple  sys- 
tem disease,  and  the  second  is  stjded  combined  system  disease. 
Both  the  peripheral  and  central  motor  neurons  may  be  involved, 
singly  or  together. 

LOCOMOTOR  ATAXIA 

{Tabes  dorsalis ;  posterior  spinal  sclerosis) 

Locomotor  ataxia  is  a  system  disease,  affecting  the  afferent  or 
sensory  tracts  of  the  cord. 

It  is  divided  into  the  following  stages: 

1.  Preataxic. 

2.  Ataxic. 

3.  Paralytic. 

The  prominent  symptoms,  as  its  name  indicates,  are  ataxia, 
inco-ordination  of  gait,  sensory  disturbances,  loss  of  reflexes;  also 
accompanied  by  atrophic  disturbances  and  impairment  of  the  spe- 
cial senses.    In  tabes  the  bones  are  brittle. 

The  symptoms  confined  to  the  preataxic  stage  are  of  shoot- 


DISEASES    OF    THE    SPIXAL    CORD  237 

ing  pains,  coming  on  at  irregular  intervals,  and  usually  in  the  legs, 
and  principally  in  the  calves.  The  patient  may  complain  of  a 
sense  of  numbness  in  the  extremities,  and  may  or  may  not  have  a 
sensation  of  constriction  about  the  body,  which  is  called  the  girdle- 
sense,  or,  if  painful,  it  is  called  the  "  girdle-pain."  The  patient 
even  now  may  develop  the  perversion  of  sensation,  as  of  some- 
thing soft,  when  really  walking  on  a  hard  surface  like  a  pave- 
ment. At  times  there  may  be  violent  paroxysms  of  pain  referred 
to  certain  internal  viscera,  the  so-called  "  gastric  crisis  "  being  the 
most  important  and  frequent  one.  This  pain  is  located  in  the  epi- 
gastric region,  and  is  accompanied  by  vomiting  and  excessive  secre- 
tion of  the  gastric  Juice.  The  attack  may  last  from  a  few  moments 
to  an  hour  or  so.  In  severe  attacks  the  prolonged  weakness  follow- 
ing may  exist  from  one  to  several  days.  The  sexual  power  is  gener- 
ally decreased  in  this  stage,  although  the  appetite  is  frequently  in- 
creased. There  may  be  difficulty  in  urination.  Upon  examination 
of  the  eye,  the  so-called  Argyll-Robertson  pupil  may  be  determined 
— this  consisting  of  a  lack  of  response  of  the  iris  to  light  stimulus, 
although  accommodation  reaction  is  preserved.  In  some  rare  cases 
there  may  even  begin  optic  atrophy  in  this  stage  of  the  disease. 

Ataxic  Stage. — This  is  the  stage  when  the  patient  usually  is 
seen  by  the  physician,  from  the  fact  that  he  does  not  report  for 
treatment  until  inco-ordination  of  gait  actually  sets  in;  or  fre- 
quently from  lack  of  diagnostic  acumen  of  the  physician  the  disor- 
der is  not  made  out  until  this  stage  is  reached.  It  is  characterized 
by  the  ataxic  gait,  which  consists  in  throwing  the  limbs  forward, 
outward,  and  downward  in  an  irregular  and  lax  fashion,  the  heel 
descending  first.  The  gait  is  more  ataxic  when  the  patient's  eyes 
are  closed  or  when  he  is  walking  in  the  dark.  Since  the  cause  of 
this  symptom  is  the  perversion  or  diminution  of  the  muscular 
sense,  the  explanation  of  a  better  locomotion  in  the  light  or  with 
the  eyes  open  lies  in  the  fact  that  the  eyesight  makes  up  for  the  im- 
paired muscular  sense.  Another  symptom  present  and  dependent 
upon  the  same  disorder  of  co-ordination  is  the  Romberg's  sign, 
which  consists  of  marked  swaying  of  the  individual,  the  feet  being 
in  the  position  of  attention.  The  sway  is  more  pronounced  so  soon 
as  the  eyes  are  closed.  Other  evidences  of  inco-ordination  are 
shown  in  muscular  movements  generally,  and  particularly  in  these 
finer  movements,  as  of  the  fingers,  the  patient  being  unable  to 
write  properly,  the  letters  being  slowly  and  irregularly  outlined. 


228 


TEEATISE    ON   NEEVOUS    DISEASES 


If  the  index-fingers  of  opposite  hands  are  brought  together  there 
will  be  found  to  be  great  inco-brdination  as  they  approach  each 
other,  or  if  brought  to  the  nose  the  same  phenomenon  will  be 
observed;  this  sign  being  also  exaggerated  by  the  patient  clos- 
ing his  eyes.  A  variety 
^  of  ataxia  called  static 
ataxia,  frequently  exist- 
ing, is  detected  by  hav- 
ing the  patient  lie  on 
his  back,  then  elevating 
the  legs  from  the  bed  in 
a  fixed  position.  If  in- 
co-ordination  exists  the 
patient  is  said  to  have 
static  ataxia.  Or  it  is 
tested  for  by  the  patient 
standing  erect,  eyes 
closed.  If  he  sways  badly, 
he  also  has  static  ataxia. 
The  latter  is  the  Eomberg 
sign,  as  indicated  above. 

In  this  stage  there 
generally  is  an  aggression 
of  all  the  other  symptoms 
mentioned,  though  in  the 
minority  of  cases  the 
painful  sensations  become 
abated,  and  pargesthesia 
will  become  lessened  or 
disappear  in  them.  The 
patient  loses  his  vigour,  and  there  is  usually  muscular  wasting  and 
weakness,  in  spite  of  preservation  of  the  digestive  function.  It 
will  be  found  in  50  per  cent  of  the  cases  that  the  optic  nerves 
degenerate,  this  being  a  primary  optic  atrophy  and  not  accom- 
panied by  the  choked  disk  of  optic  neuritis.  The  ataxic  stage  may 
last  for  many  years,  and  during  that  time  periods  of  exacerbation 
and  remission  of  the  symptoms  occur,  out  of  proportion  appar- 
ently to  the  extent  of  lesion.  This  irregularity  in  such  cases  must 
be  due  to  loss  of  nutrition  for  the  time  being,  rather  than  to 
organic  change  in  the  cord. 


Fig.  56. — Standing  Posture,  Static  Ataxia 
IN  Tabes  Dorsalis.  (Philadelphia  Hospital.) 


DISEASES    OF    THE    SPIXAL    CORD  229 

Paralytic  Stage. — This  comes  on  very  late  in  the  course  of  the 
disease,  and  signifies  muscular  paralysis,  associated  with  signs  of 
paresis.  In  this  stage  the  patient  becomes  bedridden;  develops 
more  or  less  atypical  paresis  or  progressive  paralysis  of  the  insane, 
A  very  small  per  cent  of  cases  reach  this  stage,  since  they  are 
usually  carried  off  by  some  intercurrent  malady.  The  absence  of 
the  deep  reflexes  determined  so  early  in  the  preataxic  stage  re- 
main persistently  absent  during  the  entire  course  of  the  disease. 
In  some  cases  optic  atrophy  is  an  early  symptom,  and  is  so  rapid 
in  its  onset  and  progress  that  this  class  of  cases  is  given  a  dis- 
tinctive name,  the  so-called  amblyopic  form  of  tabes.  In  these 
cases  it  is  frequent  to  find  the  ataxia  held  in  some  subjection  or 
actually  bettered  with  the  onset  of  blindness.  This  is  marked  in 
a  coloured  man  in  my  Avards  at  the  Philadelphia  Hospital,  where 
on  becoming  totally  blind  the  ataxia  is  much  lessened ;  so  with  the 
crises  from  which  he  suffered  up  to  that  time.  Other  cases  of 
tabes  may  develop  unusual  symptoms,  such  as  perforating  ulcer 
of  the  foot,  which  is  a  very  rare  condition,  occurring  in  not  more 
than  two  per  cent  of  the  cases.  There  is  a  typical  case  of  this 
complication  in  ataxia,  a  man,  aged  forty,  now  in  the  paralytic 
stage  of  the  disease,  at  the  Philadelphia  Hospital,  a  description 
of  which  ulcer  will  be  typical  of  the  condition.-  The  ulcer  extends 
from  the  base  of  the  great  toe  on  the  sole  of  the  foot,  over  the  ball, 
is  much  indurated,  but  signs  of  inflammation  are  very  slight;  the 
nutrition  of  the  surrounding  tissue  being  at  a  low  stage.  The  ulcer 
is  sharply  cut,  -|  by  f  of  an  inch  in  diameter,  and  extends  down  to 
the  depth  of  f  of  an  inch  by  a  central  sinus  which  leads  down  to 
the  metatarsal  bone.  There  is  also  a  foul  odour  emanating  from 
the  sore,  with  considerable  sanious  discharge  therefrom.  It  is  not 
at  all  painful. 

Another  unusual  development  in  tabes  is  the  arthropathy, 
which  consists  in  enlargement  of  the  joint,  generally  a  large  one, 
as  the  knee,  due  to  a  subacute  trophic  inflammation.  The  bones 
become  porous,  the  synovial  membrane  lustreless  or  entirely  dis- 
appears, the  ligaments  of  the  joints  becoming  so  relaxed  as. to 
permit  of  easy  dislocation.  Synovial  fluid  occurs  in  excess  early, 
])ut  may  later  be  absorbed,  leaving  a  much  relaxed  joint.  These 
joints  are  not  painful,  and  only  give  disturbances  by  the  enlarge- 
ment and  weakness  entailed.  The  hypotonia  of  the  muscles  about 
the  affected  joint  exaggerates  the  deformity.     (Eig.  57.) 


FiQ.  57.— Charcot  Joints    (Right  Knee  and  Both  Ankles)  in  Tabes. 
(Medico-Chirurgical  Hospital.) 


DISEASES    OF    THE    SPINAL    COED  231 

The  characteristic  feature  of  all  cases  of  tabes  is  the  dispro- 
portionate increase  of  inco-ordination  to  the  small  amount  of 
muscular  weakness  per  se  and  wasting;  so  that  in  some  cases  the 
patient  will  show  very  good  strength  of  muscle  when  the  ataxia 
is  pronounced.  Absence  of  the  Argyll-Eobertson  pupil,  the  other 
symptoms  being  present  usually,  but  rarely  occurs. 

Other  unusual  symptoms  are  the  areas  of  anaesthesia,  which 
are  generally  irregular  in  outline,  and  are  situated  upon  the  chest, 
over  the  shoulder  girdle,  or  upon  the  upper  arm,  and  disobey  the 
anatomical  rules  in  that  they  do  not  follow  the  nerve-trunks,  nor 
apparently  the  segments  of  the  cord  in  all  cases. 

The  duration  of  tabes  will  be  on  an  average  from  three  to 
thirty  years.  The  disease  is  much  more  frequent  in  males,  occur- 
ring at  about  thirty  years  in  an  average  case. 

Etiology. — It  is  a  parasyphilitic  infection  in  over  90  per  cent 
of  cases,  usually  occurring  from  eight  to  fifteen  years  after  the 
initial  lesion;  other  causes  being  overwork,  auto-intoxications,  or 
chronic  poisonings,  such  as  of  malaria,  of  which  I  have  seen  one 
case  in  a  young  man  eighteen  years  of  age. 

Patliology. — The  pathology  of  tabes  consists  in  sclerosis  of 
the  posterior  columns  of  the  spinal  cord  and  the  nerve-roots.  The 
columns  of  Clarke  and  Bu'rdach  are  particularly  involved.  The 
spinal  ganglia  and  roots  are  frequently  affected.  The  peripheral 
nerves  are  occasionally  diseased.  The  pia  mater  between  the  pos- 
terior roots  is  thickened  and  opaque,  the  posterior  roots  being 
enlarged,  while  in  advanced  cases  they  become  thinner  and  more 
translucent.  The  spinal  cord  is  reduced  in  size,  and  the  poste- 
rior columns  appear  to  be  shrunken  and  present  a  grayish  ap- 
pearance. The  first  sclerotic  areas,  as  a  rule,  are  found  in  the 
posterior  roots,  usually  in  the  lumbar  region  and  in  the  tract 
of  Lissauer;  next  the  columns  of  Burdach  are  affected,  beginning 
along  the  median  side  of  the  posterior  horns,  spreading  out 
towards  the  posterior  median  seeptum,  finally  involving,  as  in- 
ferred, the  column  of  Goll ;  and  may  ascend  to  the  upper  thoracic 
and  cervical  regions,  the  usual  seat  of  lesion  being  confined  to  the 
lumbar  cord.  The  fine  fibers  running  from  the  posterior  roots  to 
the  column  of  Clarke  are  also  sclerosed,  but  the  cells  then  are  not 
usually  destroyed,  and  consequently  the  direct  cerebellar  tract  is 
rarely  degenerated. 

Diagnosis, — Tabes  should  not  be  confused  with  any  other  dis- 


232  TREATISE    ON    NERVOUS    DISEASES 

ease,  save  possibly  syringomyelia,  where  the  dissociation  of  sensa- 
tion in  the  latter  and  muscular  atrophies  would  be  distinguishing 
points.  Chronic  multiple  neuritis,  with  ataxia,  would  be  deter- 
mined by  the  muscular  atrophy  again;  also  by  tenderness  over  the 
inflamed  nerves,  so  that  in  studying  a  given  case  the  presence  of 
shooting  pains,  absence  of  knee-jerks,  the  presence  of  Argyll-Rob- 
ertson pupil  with  or  without  optic  atrophy,  and  history  of  syphilis, 
there  would  be  very  little  doubt  as  to  tabes  being  present.  There 
is  increase  of  knee-jerks  in  ataxic  paraplegia. 

Prognosis. — While  complete  recovery  rarely  occurs,  much  can 
be  done,  however,  to  ameliorate  the  symptoms  and  to  lengthen  the 
period  before  the  paralytic  stage  should  occur.  Ten  years  is  an 
average  duration. 

Treatment. — In  an  early  case  usually  antisyphilitic  measures 
are  indicated,  since  it  is  possible  that  some  remnants  of  the  patho- 
logical exudate  of  the  third  stage  of  syphilis  should  exist,  which 
the  use  of  the  iodides  and  mercury  by  the  sorbefacient  and  altera- 
tive action  may  tend  to  dissipate.  Prolonged  active  antisyphilitic 
treatment  should  not  be  carried  on  after  it  is  noted  that  distinct 
improvement  has  not  occurred.  In  debilitated  cases  a  combination 
of  cod-liver  oil  with  the  alterative  drugs,  as  arsenic,  should  be  em- 
plo3'ed.  In  anaemic  persons  the  use  of  iron  is  indicated.  If  after 
a  thorough  trial  benefit  is  not  had,  some  of  the  following  drugs 
may  be  used  until  the  one  is  determined  that  particularly  benefits 
the  case.  Arsenic  given  in  the  form  of  Donovan's  solution,  4  drops 
t.  i.  d. ;  or  the  chloride  of  gold  and  sodium,  ^i_  gr.  t.  i.  d. ;  and  the 
glycero-phosphate  of  lime  or  soda.  Long-continued  doses  of  sil- 
ver nitrate,  |  gr.  t.  i.  d.,  have  been  found  efficacious  by  some  ob- 
servers. Strychnine  may  be  resorted  to  in  cases  where  there  is 
much  weakness,  although,  as  a  rule,  strychnine  is  not  an  ideal 
drug,  often  making  the  patient  irritable  and  exaggerating  his 
ataxia  on  account  of  muscle  stimulation.  In  addition  to ,  drugs 
the  patient  should  be  instructed  to  abstain  from  alcohol,  tobacco, 
and  sexual  indulgence,  and  he  should  have  plenty  of  nutritious 
proteid  food,  fresh  air,  and  sunshine.  The  overuse  of  the  lower  ex- 
tremities, as  in  a  half-hour's  walk,  is  baneful.  Exercises  shouldbe 
rather  of  a  passive  nature ;  hence  the  ideal  treatment  for  a  case  of 
tabes  is  the  "rest  cure,"  plus  the  use  of  massage  and  SM^ertish 
movements  by  an  experienced  manipulator.  In  mild  cases,  where, 
the  patient  is  going  about,  the  method  first  introduced  by  Weir 


DISEASES    OF    THE    SPINAL    COED  233 

Mitchell  and  later  amplified  by  Frankel  is  important.  This  con- 
sists in  a  series  of  educational  movements,  the  patient  lying  on  his 
back  and  approximating  his  toes  and  his  fingers  together,  etc. ; 
finally  walking  along  a  crack  in  the  floor  and  stepping  over 
bricks  placed  upon  the  floor,  with  the  eyes  opened,  then  closed. 
As  the  patient  improves  he  is  instructed  to  do  more  difficult  exer- 
cises, such  as  walking  backward  under  the  same  conditions. 

•  Warm  sponge  baths  given  at  night  are  valuable  in  the  relief  of 
pain,  and  by  the  stimulation  of  secretion  to  the  carrying  off  tox- 
ines  from  the  system.  The  warm  bath  (temperature  of  150°  F.) 
must  not  last  longer  than  fifteen  minutes,  and  should  be  followed 
by  a  cold  spray  down  the  spine  for  two  or  three  minutes,  the  tem- 
perature of  the  water  being  about  60°  F.  The  entire  procedure 
thus  far  should  be  folloAved  by  a  brisk  rub  with  a  Turkish  towel, 
in  order  to  stimulate  the  superficial  circulation,  and  thereby  to 
relieve  congestion  about  the  posterior  roots  of  the  spinal  cord. 
Another  measure  not  used  sufficiently  for  the  relief  of  tabes,  and 
especially  the  painful  cases,  is  to  resort  to  high  altitudes,  above- 
5,000  feet,  in  a  dry  climate.  Such  cases  I  have  seen  benefited  in 
Colorado  and  Kew  Mexico. 

Suspension  treatment  is  a  valuable  measure  also  in  some  cases 
to  relieve  pain.  It  consists  in  suspension  of  the  patient  by  lift- 
ing the  body  to  the  tip-toes  by  means  of  a  head-piece  about  the  chin 
and  occiput  and  under  the  elbows.  The  seance  should  last  three 
to  five  minutes  once  or  tv/ice  a  week.  It  relieves  pain  by  stretch- 
ing the  spinal  ligaments  and  aiding  circulation  about  the  nerve- 
roots. 

Drugs  to  relieve  pain  should  be  only  used  with  great  precaution 
for  fear  that  the  patient  may  form  the  drug  habit.  Antipyrine 
can  be  given  in  5-grain  doses;  a  combination  of  the  analgesics 
with  codeine,  ^  to  |  grain,  is  frequently  very  valuable ;  a  hypoder- 
mic injection  of  morphine,  i  to  |  grain,  guarded  by  atropine,  -s|-o 
of  a  grain,  must  be  given  to  control  crises.  To  relieve  the  tingling 
and  numbness  of  the  legs  static  electricity  administered  thrice 
weekly  is  good  treatment;  but  more  particularly  is  the  use  of  the 
Faradie  '^  dry  brush  "  an  excellent  procedure  in  these  cases.  Coun- 
ter-irritation by  blister  or  cautery  over  the  lumbar  spine  at  times 
acts  remarkably  well  in  alleviation  of  painful  paroxysms. 

Of  great  importance  is  the  nutritive  state  of  the  patient, 
which  should  be  carefully  watched  at  all  times  even  to  the  holding 


234  TKEATISE    ON    NEEVOUS    DISEASES 

in  abeyance  all  other  treatment,  since  if  nutrition  is  not  pre- 
served improvement  will  not  take  place.  Eed  meats,  eggs,  oysters, 
cereals,  good  bread  and  butter  and  milk,  in  as  large  quantities  as 
the  patient  is  able  to  digest,  are  the  ideal  foodstuffs  that  should  be 
employed. 


DISEASES  OF  THE  MOTOR  NEURONS  OF  THE 
SPINAL  CORD 

Primary  Lateral  Sclerosis 

This  is  a  disease  characterized  by  a  paralysis  of  the  muscles, 
beginning  usually  in  the  lower  extremities,  and  attended  with  in- 
creased reflexes,  but  unattended  by  muscular  atrophy  or  sensory 
disturbances.  This  disease  occurs  most  frequently  between  the 
ages  of  twenty  and  forty.  It  may  appear  earlier,  as  reported  in  a 
case  by  H.  IST.  Moyer  in  a  child  of  five  years.  I  have  seen  for  some 
years  a  case  with  Sinkler,  reported  by  that  gentleman  and  myself 
in  a  paper  on  family  diseases,  already  referred  to.  In  this  case — a 
woman  about  thirtj^-eight  years  of  age — the  disease  began  about 
twenty  years  ago,  and  has  been  very  slow  in  progress.  Some  cases 
have  been  supposed  to  follow  syphilitic  infection,  or  to  be  caused 
again  by  hereditary  syphilis  or  alcoholism  transmitted  from  the 
parents.  Others  have  appeared  to  be  due  to  traumatism  to  the 
back,  or  to  exposure  to  cold  and  wet,  and  to  certain  infectious  dis- 
eases; or  to  excesses,  predisposing  to  general  physical  debility 
through  excessive  drain  on  the  nervous  system. 

Symptoms.— "The  patient  first  complains  of  rigidity  with 
weakness  of  the  muscles  of  the  lower  extremities,  which  may  be 
associated  with  a  sense  of  fatigue  or  dull  pains,  but  never  of  an 
active  character.  The  symptoms  may  first  commence  in  one  leg 
before  the  other  is  at  all  affected,  or  one  may  be  affected  more 
than  the  other.  The  loss  of  power  is  very  gradual  and  not  at  all 
in  proportion  (as  in  ataxia)  to  the  impairment  of  progression, 
which  in  this  instance  is  due  to  spasticity.  The  extremity  soon 
becomes  rigid,  so  that  on  flexing  the  joint  a  sensation  as  of  bend- 
ing a  piece  of  lead  pipe  is  transmitted  to  the  examiner.  If  the 
movement  is  continued  the  rigidity  lessens.  The  gait  in  the  very 
beginning  is  slightly  spastic,  as  shown  by  the  patient  wearing  the 
shoes  out  at  the  toes  or  complaining  of  tripping  over  slight  impedi- 


DISEASES    OF    THE    SPINAL    CORD  235 

ments.  Later  the  characteristic  spastic  gait  prevails,  and  the 
feet  appear  glued  to  the  ground  and  are  pushed  forward  with 
effort.  The  toes  are  raised  over  obstacles  with  great  difficulty. 
Voluntary  effort  increases  the  clonic  and  tonic  spasms  of  the  mus- 
cles, and  owing  to  spasm  of  the  adductor  and  stronger  muscles  the 
knees  are  kept  close  together,  and  in  aggravated  cases  there  is 
often  cross-legged  progression.  The  knee-jerks  are  markedly  in- 
creased and  ankle  clonus  well  developed,  although  not  so  large  as 
in  cases  of  insular  (or  disseminated)  sclerosis.  The  superficial  re- 
flexes are  slightly  increased.  Muscles  are  not  wasted,  excepting 
that  resulting  from  disuse.  They  feel  firm  to  the  touch.  The 
sphincters  are  not  involved  until  very  late  in  the  course  of  the  dis- 
ease. Sensory  disturbances  are  absent,  other  than  paresthesia,  the 
result  of  circulatory  disturbances  from  vaso-motor  weakness.  The 
upper  extremities  do  not  become  involved  until  late  in  the  course 
of  the  disease.  Seldom  do  trophic  ulcerations  occur,  but  the  affect- 
ed extremities  are  very  easily  frost-bitten.  The  patient  may  live 
many  years  in  comparative  comfort,  other  than  the  physical  dis- 
tress of  being  thus  disabled  from  active  life. 

Pathology. — This  consists  in  a  degeneration  in  the  pyramidal 
tracts.  That  this  may  occur  primarily  is  not  definitely  settled,  and 
many  observers  believe  that  degeneration  of  the  pyramidal  tracts 
alone  cannot  occur,  except  as  a  secondary  degeneration  due  to 
lesion  higher  up.  A  few  cases  have  been  reported,  however,  in 
which  no  such  primary  lesion  could  be  found. 

Diagnosis. — In  transverse  myelitis  sensory  symptoms  are  more 
pronounced,  the  disease  is  more  acute,  anaesthesia  frequent,  and  the 
sphincters  are  early  affected.  In  ataxic  paraplegia  the  spasticity  of 
the  muscles  is  not  so  marked  and  evidence  of  lack  of  co-ordina- 
tion is  present;  involvement  of  the  sphincter  is  also  common.  In 
amyotrophic  lateral  sclerosis  there  is  muscular  atrophy,  not  noted 
in  the  disease  under  consideration.  Secondary  degeneration  fol- 
lowing cerebral  apoplexy  may  rarely  be  mistaken  for  cases  of  pri- 
mary lateral  sclerosis,  in  which  one  side  is  more  affected  than  the 
other.  The  history  of  a  previous  apoplexy  would,  of  course,  settle 
the  question.  Hysterical  paraplegia  may  quite  often  be  difficult  to 
distinguish.  In  lateral  sclerosis  rigidity  of  limbs  is  more  pro- 
nounced when  they  are  extended,  and  vice  versa,  a  condition  that 
does  not  occur  in  hysteria.  Also  the  deep  reflexes,  while  they  may 
be  increased,  are  not  so  much  so  in  hysteria.     True  ankle  clonus 


236  TREATISE    ON    NERVOUS    DISEASES 

is  exceedingly  rare  in  the  disease  under  consideration.  Other 
evidences  will  also  be  found,  such  as  "stigmata''  or  hysterical 
paroxysms,  which  are  more  frequent,  too,  in  females. 

Prognosis. — The  prognosis  of  the  disease  is  steadily  slowly 
onM^ard  and  downward  until  the  power  of  progression  is  lost.  The 
patient  may  live  for  twenty  or  thirty  years,  and  die  as  the  result 
of  an  intercurrent  disease,  although  involvement  of  the  bulb  may 
through  inhibition  of  the  vagus  cause  death  from  heart  fail- 
ure. 

Treatment. — This  is  not  very  satisfactory.  Nitrate  of  silver, 
chloride  of  gold  and  sodium,  iodide  of  potassium,  etc.,  may  be 
of  service.  Massage  is  a  valuable  agent  in  arresting  muscular 
wasting.  The  electric  brush  is  also  of  use  in  stimulating  the  cir- 
culation. The  patient  should  be  well  fed,  given  the  hypophosphites 
from  time  to  time,  and  must  be  well  protected  with  woollen  cloth- 
ing. Strychnine  is  contra-indicated,  as  it  excites  the  muscular 
spasms  in  already  irritable  muscle  fibres. 

SPASTIC  SPINAL  PARALYSIS 

Spastic  Paralysis 

This  term  applies  to  a  form  of  paraplegia  caused  by  (a)  chronic 
myelitis,  as  well  as  to  a  (h)  congenital  disorder  in  which  there  is 
sclerosis  of  the  lateral  columns  of  the  cord.  There  has  been 
much  controversy  as  to  the  latter,  some  giving  the  name  of  Lit- 
tle's disease  to  the  diplegic  or  paraplegic  forms  of  the  cerebral  pal- 
sies of  childhood,  though,  properly  speaking,  this  should  be  ap- 
plied to  lateral  sclerosis.  Little  first  described  the  condition  in 
1846  and  in  1877.  In  1873  and  in  1879  Dr.  E.  C.  Seguin,  of 
New  York,  described  a  condition  of  similar  type  which  he  called 
"tetanoid  paraplegia."  Erb  and  Charcot  in  France  independ- 
ently in  1875  published  articles  on  "spasmodic  spinal  paralysis" 
and  "spasmodic  dorsal  tabes"  respectively.  After  this  there  was 
much  confusion.  Finally,  the  spastic  paralysis  has  been  shown 
to  be  due  to  spinal,  associated  probably  with  cerebral  defect. 

Etiology. — It  is  congenital  and  due  to  lack  of  development  of 
the  pyramidal  tracts,  which  leads  to  a  sclerosis  of  the  lateral  col- 
umns and  to  symptoms  of  spasticity  of  legs  and  arms,  exaggerated 
reflexes,  with  some  weakness,  and  at  times  slight  atrophy.  Pre- 
natal or  natal  in  its  origin,  it  is  primarily  an  agenesis  in  the  first 


DISEASES    OF    THE    SPINAL    COED  237 

instance;  or  if  caused  at  birth,  as  Little  supposed,  may  be  due  to 
premature  or  forced  deliveries.     It  may  be  a  family  disease. 

Symptoms  appear  shortly  after  birth,  usually  within  a  year, 
but  may  appear  after  the  fifth  year  in  family  types,  or  even 
after  maturity.  There  is  a  type  of  this  disease  I  have  seen  where 
the  spasticity  remains  entirely  in  the  lower  extremities,  coming  on 
at  about  fifteen  years  of  age,  and  not  affecting  the  upper  extremi- 
ties at  all.  In  the  ordinary  type  it  is,  as  inferred,  difficult  to  dis- 
tinguish spastic  spinal  paralysis  from  the  cerebral  palsies  (or 
''birth  palsies,"  so  called).  The  lack  of  marked  mental  impair- 
ment is  a  point  in  differentiation,  the  brain  seeming  to  be  spared 
except  for  its  motor  areas  being  damaged.  At  times,  too,  lateral 
sclerosis  cases  occasionally  gain  in  development,  and  some  in- 
crease in  the  use  of  the  limbs  follows  more  than  in  cerebral  palsies. 
The  so-called  "  scissor-legs "  frequently  are  found  in  these  pa- 
tients, the  crossing  of  the  limbs  being  exaggerated  in  the  efforts  of 
walking..  The  arms  are  much  less  affected  than  the  legs.  The 
throat  and  facial  muscles  may  be  slightly  involved.  In  some  cases 
the  disability  increases  quite  rapidly.  There  is  no  pain,  however. 
The  arms  may  later  be  contractured.  Finally  the  patient  becomes 
helpless.  Epilepsy  or  mental  deterioration  may  develop  at  the 
time  of  puberty  or  adolescence. 

Prognosis. — The  mild  cases  that  learn  how  to  walk  should  be 
kept  carefully  at  the  practice  of  their  muscles,  when  they  may 
slowly  improve  and  reach  average  health  and  adult  age.  Severe 
cases  rarely  reach  adolescence,  and  generally  die  of  some  inter- 
current disease  before  the  twenty-first  year  of  age. 

Diagnosis. — It  is  distinguished  from  the  cerebral  (or  birth) 
palsies  by  the  absence  of  any  material  initial  mental  defect,  micro- 
cephalus,  or  of  epilepsy.  From  compression  myelitis  spastic  paral- 
ysis is  distinguished  by  the  affection  of  the  arms,  the  absence 
of  pain,  and  of  disturbance  of  the  sphincters.  Hereditary  spastic 
palsy,  which  is  also  found  to  occur  in  families,  begins  later  (at 
about  the  fifth  year,  see  p.  238),  and  involves  the  legs  chiefly. 

Treatment  consists  in  orthopgedics,  massage,  and  Swedish  move- 
ments to  prevent  contractures  and  deformities.  General  nutri- 
tion must  be  carefully  maintained;  also  the  protection  of  the  body 
from  cold  or  extremes  of  temperature.  Employment  of  tenotomy 
may  be  necessitated  where  mechanical  treatment  fails,  in  which  case 


238  TREATISE    OS    XERVOrS    DISEASES 

braces  should  be  applied  to  retain  the  normal  position  of  the 
limbs,  and  the  child  then  encouraged  to  walk  about  by  means  of  the 
wheel  crutch  or  other  form  of  apparatus.  Many  cases  have  been 
improved  so  as  to  walk  with  some  facility  by  persistence  in  this 
■regard,  and  a  hopeless  life  of  invalidism  stayed. 

HEREDITARY  SPASTIC  SPINAL  PARALYSIS ^ 

This  disease  is  of  the  family  type,  affecting  different  members 
of  succeeding  generations.  It  begins  about  the  age  of  five,  affects 
mainly  the  legs,  runs  a  very  slow  course,  is  not  accompanied  by 
pain,  ataxia,  or  visceral  symptoms,  and  may  continue  for  thirty 
years  or  more.  The  writer  has  two  cases  of  this  rare  affection 
under  observation  where  there  seems  to  be  a  remission  of  all 
symptoms  within  the  last  six  months. 

FRIEDREICH'S  DISEASE,  OR  HEREDITARY  ATAXIA 

This  is  a  developmental  disease,  occurring  in  early  youth,  is 
more  frequently  met  with  in  males  than  in  females,  and  the  symp- 
toms very  frequently  begin  at  about  the  tenth  year,  the  patient 
having  been  in  apparent  good  health  up  to  that  time,  although 
undoubtedly  of  vulnerable  nerve  protoplasm.  There  may  be  found 
a  history  of  heredity,  although  the  affection  is  never  congenital ;  or 
there  will  be  a  history  of  syphilis  or  alcoholism  in  the  progenitors, 
usually  in  the  parents. 

Symptoms. — These  cousist  first  in  ataxia,  very  much  like  that 
of  tabes,  but  accompanied  by  irregular  choreiform  movements, 
perhaps  athetosis,  as  in  a  case  reported  by  Swan  and  myself 
(Philadelphia  Medical  Journal,  January,  1896).  The  speech  is 
frequently  affected  in  this  disease,  staccato-like  and  drawling, 
accompanied  by  dribbling  of  saliva  from  the  mouth,  inability  to 
masticate  food  properly,  and  by  dysphagia.  The  mental  condition 
remains  fairly  good,  although  one  is  apt,  from  the  mechanical  de- 
fects, to  appear  feeble-minded,  a  condition  similar  to  the  pseudo- 
imbecility  in  some  cases  of  spastic  paralysis  of  childhood,  where 
mental  failure  is  exaggerated  by  the  fact  that  the  vocal  muscles  are 


1  In  all  these  so-called  spinal  spastic  paralyses  occurring  in  early  life  there 
must  be  some  cerebral  defect  or  agenesis,  though  the  degeneration  is  largely 
associated  with  the  lateral  tracts  of  the  spinal  cord. 


DISEASES    OF    THE    SPINAL    COED  239 

spastic.  The  Arg-yll-Kobertson  pupil  is  not  so  constant  as  in 
tabes  dorsalis,  but  there  is  often  present  nystagmus,  usually  bilat- 
eral. The  knee-jerks  are  not  constantly  absent,  though  usually  so, 
and  may  change  from  year  to  year  in  accordance  with  the  in- 
volvement of  the  posterior  columns,  lateral  columns,  or  anterior 
horns  of  the  cord  in  varying  degrees,  and  thus  disturbing  the 
physiological  reaction  of  these  parts  as  the  disease  picture 
changes.  The  patient  may  also  develop  club-feet — the  equino- 
varus  position  being  particularly  common — due  to  contraction  of 
the  posterior  leg  muscles.  Localized  muscle  atrophy  is  in  evi- 
dence, and  where  this  occurs  fibrillary  twitchings  will  also  be 
found.  Curvature  of  the  spine  is  another  symptom  that  may 
exist,  dependent  upon  muscular  weakness  of  the  erector  spinas 
group.  Trophic  joints  are  very  rare  indeed.  Pargesthesia  may 
exist.     In  Marie's  cerebral  type  cerebellar  gait  exists. 

Pathology. — This  consists  in  an  overgrowth  of  neuroglia 
cells  within  the  central  nervous  system,  particularly  involving  the 
posterior  roots  and  posterior  columns  of  the  spinal  cord.  In 
addition  round-cell  infiltration  may  be  present  in  other  parts  of 
the  cord  about  the  anterior  horns  and  in  areas  diffused  through- 
"out  the  brain.  It  is  undoubtedly  the  remnant  of  an  embryological 
defect  in  the  child,  which  by  the  developmental  period  first  gives 
expression  to  symptoms,  just  as  syringomyelia  gives  rise  to  symp-^ 
toms  due  to  a  gliosis  commencing  in  prenatal  life  from  defect  in 
the  embryo  itself. 

Diagnosis. — This  disease  should  not  be  confounded  with  any 
other.  Diagnosis  may  lie  between  it  and  spastic  paralysis  of  child- 
hood, which  latter  presenting  increase  of  reflexes  in  the  spastic 
condition  with  more  marked  athetosis  and  lack  of  atrophies,  would 
be  sufficient  signs  for  the  proper  diagnosis  of  this  disease.  Insular 
sclerosis  is  told  by  the  more  pronounced  nystagmus,  increase  of 
reflexes  and  its  later  development.  From  tabes,  the  earlier  devel- 
opment of  Friedreich's  disease,  the  lack  of  crises,  and  the  type  of. 
movements  (choreic)  will  make  it  clear. 

Prognosis. — The  patient  may  live  for  many  years,  but  usually 
does  not  reach  maturity. 

Treatment. — This  is  solely  palliative,  and  consists  in  proper 
nutrition ;  hygiene,  as  to  clothing  and  exercise,  which  latter  should 
be  limited,  though  systematic,  and  particularly  in  the  form  of 


240  TEEATISE   OX   XervOUS   DISEASES 

calisthenics  towards  preventing  contractions;  for  which  massage 
and  SAvedish  movements  are  also  valuable  agents.  Drugs,  sucli  as 
potassium  iodide,  in  small  continuous  dosage,  also  the  chloride  of 
gold  and  soda,  -^-^  gr.  t.  i.  d.,  and  in  atonic  cases  the  use  of  strych- 
nine will  be  of  great  service.  For  the  prevention  of  deformities, 
or  where  they  exist  already,  the  use  of  a  "  brace  "  may  be  necessary 
to  the  spinal  column  or  to  the  lower  extremities,  and  in  some  cases 
the  use  of  crutches  will  be  of  value  in  permitting  the  patient  to 
move  about.  These  subjects  are  very  liable  to  become  bedridden, 
so  that  educational  movements  should  be  faithfully  .tried. 

CEREBELLAR  ATAXIA 

This  is  also  an  hereditary  disease,  and  begins  later  in  life  than 
Friedreich's  disease — from  fifteen  to  eighteen  years  of  age. 

Symptoms. — It  is  particularly  characterized  by  the  cerebellar 
or  titubating  gait  added  to  the  other  sj^mptoms  of  ataxia.  The 
knee-jerks  are  increased,  diminished,  or  precocious  in  this  dis- 
ease, but  there  is  seldom  found  ankle  clonus.  The  duration 
of  the  affection  may  be  for  many  years  (eight  or  ten),  the 
patient  generally  dying  of  some  intercurrent  affection.  Club- 
feet are  very  apt  to  develop,  due  to  contractions,  the  gait  being 
somewhat  similar  to  that  of  ataxic  paraplegia.  The  patient  pre- 
sents no  sensory  symptoms. 

Pathology. — This  consists  in  degeneration  of  cells  of  Purkinje 
in  the  cerebellum  and  the  posterior  columns  of  the  spinal  cord. 
Atrophy  of  the  optic  nerve  may  exist  and  nystagmus  may  be 
present. 

Treatment. — This  is  symptomatic.  The  use  of  the  hypophos- 
phites  and  nutritional  measures  with  calisthenics  and  Swedish 
movements  as  described  under  the  previous  disease.  For  the  pre- 
vention of  deformities  of  the  legs  braces  should  be  applied  by  the 
orthopaedic  surgeon. 

FUNCTIONAL  DISORDERS   OF  THE  SPINAL  CORD 

Functional  disorders  of  the  spinal  cord  include  those  of  irrita- 
tion or  of  depression  coming  under  the  head  of  spinal  neurasthenia, 
or  spinal  irritation,  or  spinal  exhaustion.  These  symptoms  are 
described  under  the  head  of  Neurasthenia  (see  Chapter  XVI). 


DISEASES  OF  THE  SPIXAL  COED 


241 


CAUDA  EQUINA 

The  Cauda  equina  is  made  up  of  five  lumbar,  from  five  sacral 
and  one  coccygeal  (Muller),  nerve-roots.  They  lie  within  the 
dura,  extending  beyond  the  spinal  cord  some  15  centimetres. 
These   distinct   motor   and 

sensory  roots  do  not  quite     [  -. — ....■  TV 

unite  until  they  pass  out 
of  the  dura.  The  cauda 
begins  at  the  lower  edge 
of  the  second  lumbar  ver- 
tebra. The  term  conus  is 
applied  to  the  part  of  the 
cord  below  the  second 
sacral  segment.  In  this 
part  (conus)  the  anterior 
root-fibres  are  smaller  and 
fewer  in  number  than  the 
posterior  or  sensory  root- 
fibres.  Muller  gives  the 
arrangement  of  the  vis- 
ceral centres  as  follows : 
Second  sacral,  erection 
centre;  third  sacral,  ejac- 
ulation centre ;  fourth 
sacral,  bladder  (detrusor) 
centre ;  fifth  sacral,  sphinc- 
ter ani  centre. 

Symptoms  and  Diag- 
nosis.—  The  diagnosis  of 
cauda  lesions  involves  a 
study  of: 

1.  Lesions  of  the  lower 
end  of  the  cord. 

2.  Cauda  compression,  irritation,  or  destruction. 

3.  Lesions  of  the  peripheral  nerves. 

1.  Lesions  of  the  loiver  end  of  the  cord  generally  come  on  rap- 
idly, in  a  few  days,  following  myelitis,  etc.     There  is  little  pain, 

and  dissociation  of  sensation  comes  on  late. 
16 


Fig.  58.— Tumour  (Psammoma)  springing 
FROM  Dura,  Lower  Dorsal  Cord. 
(Specimen  from  Philadelphia  Hospital.) 


242  TREATISE    OX    XERVOUS    DISEASES 

Fibrillary  contractions  and  involuntary  twitcliings  of  the  leg 
muscles  occur.  *  Paralysis  rapidly  appears,  involving  the  lower 
limbs  in  accordance  with  the  segmental  distribution  of  the  nerves. 
It  is  a  flaccid  palsy  and  is  followed  by  atrophy.  The  visceral  cen- 
tres are  involved.  If  the  conus  is  not  implicated  the  paralysis 
does  not  seriously  involve  these  centres  nor  the  muscles  of  the 
pelvic  girdle.  The  motor  symptoms  are  far  more  prominent  than 
sensory  symptoms.  The  cord  being  small  is  easily  destroyed,  and 
very  little  improvement  ever  occurs. 

2.  In  disease  of  the  cauda,  since  it  is  usually  a  neoplasm,  the 
symptoms  generally  come  on  slowly.  In  injury  the  symptoms 
appear  rapidly  after  the  trauma.  There  is  often  severe  pain  in  the 
bladder,  in  the  sciatic  distribution,  and  it  is  bilateral.  Anass- 
thesia  in  the  area  of  the  sciatic  nerves  follows  later.  The  paraly- 
sis is  slow  in  development.  The  sensory  symptoms  are  far  more 
prominent  than  the  motor  at  all  times.  The  sexual  bladder  and 
rectal  centres  are  later  paralyzed.  Sometimes  prompt  operation, 
as  in  tumour,  will  give  quick  relief.  This  should  always  be  done 
where  tumour  is  suspected,  otherwise  the  case  is  hopeless  as  to 
cure.  The  symptoms  in  compression  of  the  cauda  without  de- 
struction are  like  compression  of  the  cord,  but  there  is  less  motor 
disturbance,  and  there  may  be  no  involvement  of  the  sphincters. 

3.  Lesions  of  the  peripheral  nerves  (neuritis  or  injury)  is 
rapid  in  onset.  There  are  sciatic  pains — tender  spots  along  the 
nerve-trunks.  ■  The  lesion  may  be  only  unilateral,  the  pain  being 
not  so  severe,  and  there  is  no  m.arked  antesthesia.  There  is  little 
or  no  paralysis  of  the  visceral  centres,  the  sensory  slightly  pre- 
dominating. There  is  often  a  history  of  sciatica  or  alcoholism^  or 
injury.  Examination  may  disclose  the  presence  of  a  tumour  or  of 
some  disease  affecting  directly  the  sciatic  plexus;  and  the  prog- 
nosis is  favourable. 


CHAPTEE  -XIY 

DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL   CORD 

SPINAL   HYPERyEMIA,  ACUTE  AND   CHRONIC 

2Etiology. — Violent  physical  exertion,  sexual  excesses,  amenor- 
rhoea,  and  certain  poisons,  as  strychnine,  are  causes  of  spinal 
hyperaemia.  It  is  also  the  first  stage  of  acute  inflammatory  dis- 
eases. Chronic  spinal  liypercemia  is  rare.  It  may  occur  in  the 
membranes  as  the  result  of  meningitis  or  injury.  There  is  no 
absolute  knowledge  of  separate  chronic  hypersemia  of  the  cord. 

Symptoms  are  of  a  sense  of  weight  aroundthe  loins,  of  heavi- 
ness, twitching  of  the  muscles,  a  numbness,  formications,  and 
actual  pain  of  a  neuralgic  nature,  accompanied  by  numbness  of 
the  lower  extremities.  The  sphincters  may  be  involved.  The 
symptoms  are  as  inferred,  usually  confined  to  the  lower  extremi- 
ties. The  position  of  the  patient,  as  mentioned  by  some  authors, 
can  have  but  little  influence  upon  symptoms  due  to  spinal  hyper- 
aemia. The  signs  and  symptoms  of  chronic  spinal  hyperemia  are 
much  like  those  of  spinal  irritation.  They  will  be  described 
under  that  head. 

Pathology. — The  circulation  of  the  blood  in  the  spinal  cord, 
as  has  been  shown  in  the  chapter  on  Anatomy,  is  one  which  is  diffi- 
cult to  disturb ;  but  if  so,  if  is  slow  in  being  brought  back  to  nor- 
mal. The  violent  activity  of  the  heart  and  great  increase  in  arte- 
rial pressure,  and  then  the  weakened  state  of  the  heart  muscle  and 
lowered  tension,  appear  to  modify  but  little  the  spinal  functions. 
Hence  it  is  unlikely  that  the  large  number  of  clinical  symptoms 
that  have  been  attributed  to  the  circulatory  failure  are  so  caused. 

Treatment. — This  consists  in  the  application  of  cups  to  the 
back,  rest  in  the  horizontal  position,  better  upon  the  side  or  face, 
counter-irritation  to  the  spine,  or  the  use  of  cold,  as  in  the  form 
of  ice-bags.  Among  drugs  the  employment  of  bromides  and  mor- 
phine is  good  treatment.    The  sorbefacient  and  alterative  effect  of 

243 


244  TREATISE    ON   HERYOUS    DISEASES 

chloride  of  ammonium  and  the  iodides  is  recommended ;  or  the  use 
of  galvanic  electricity,  the  negative  pole  being  placed  over  the- 
spine  and  the  positive  at  some  indifferent  point  (5  minutes). 

SPINAL  ANEMIA 

Spinal  anaemia  is  less  known  in  its  cause,  symptomatolog)^, 
and  course  than  is  hypergemia.  It  is  more  apt  to  affect  the 
posterior  columns  than  the  ventral  aspect  of  the  cord,  for  the 
reason  that  the  dorsal  nutritive  arteries  are  smaller  than  the  an- 
terior ones.  Severe  hsemorrhages  or  extreme  diarrhoeas  may  be 
predisposing  factors  by  causing  general  anaemia.  Or  aortic  obstruc- 
tion, as  in  aneurysm,  may  be  the  cause  (through  cutting  off  blood 
supply  to  the  cord)  of  almost  total  abolition  of  cord  function.  It 
is  not  common  for  serious  disturbance  of  the  cord  to  persist  from 
anemia  excepting  where  there  is  disease  of  the  arteries,  and  in  that 
event  the  sclerosis  of  the  posterior  columns  may  follow  in  the  wake 
of  an  added  pernicious  anaemia,  in  which  latter  the  general  symp- 
toms overshadow  those  of  the  spinal  cord.  The  test  of  the  patient's 
improvement  when  lying  on  his  back  is  perhaps  incorrect.  Some 
writers  associate  with  sjoinal  anemia  a  class  of  symptoms  such 
as  pain  in  the  back  and  weakness  of  the  legs,- which  may  amount  to 
paraplegia,  a  group  of  symptoms  that  has  been  given  the  name 
of  spinal  concussion,  but  it  is  impossible  to  scientifically  state 
whether  spinal  anaemia  is  the  underlying  condition  in  such  cases. 

SPINAL   HAEMORRHAGE 

Spinal  Apoplexy 

This  general  name  may  be  given  to  (1)  hsematorrhachis  or 
spinal  meningeal  haemorrhage,  and  (2)  hsematomyelia  or  hsem- 
orrhage  into  the  cord  substance. 

(1)  Spinal  meningeal  haemorrhage  is  the  most  usual  form,  and 
may  be  extradural  or  intradural.  Extradural  haemorrhage  is  the 
more  usual  disease. 

Etiology. — It  is  more  common  in  men  than  in  women.  It 
also  oc^-urs  in  newly  born  children.  Falls,  injuries,  and  fractures 
of  the  spine  are  the  most  usual  causes.  Convulsive  seizures  due  to 
epilepsy,  tetanus,  chorea,  eclampsia,  or  strychnine  may  cause  it, 
the  same  as  in  severe  muscular  strain.    The  various  dyserasiae  fol- 


DISEASES    OF    THE  _  SPINAL    CORD  245 

lowing  infectious  diseases,  such  as  purpura,  may  cause  it ;  or  it  may 
be  due  to  the  bursting  of  an  adjacent  aneurysm,  such  as  of  the 
aorta  or  vertebral  artery,  and  in  very  rare  instances  cerebro-spinal 
meningitis. - 

Symptoms. — There  may  be  no  ascertainable  symptoms  in 
minute  hsemorrhages.  In  large  hsemorrhage  there  is  sudden  se- 
vere pain  in  the  back,  shooting  down  the  limbs,  associated  witlr- 
numbness,  hypersesthesia,  muscular  spasm,  generally  of  the  back 
muscles;  later,  paresis,  paralysis,  and  ansesthesia  may  follow,  with 
disorder  of  the  visceral  centres.  The  disease  is  fulminating, 
reaching  its  acme  in  the  course  of  a  few  hours.  Remission  may 
then  occur,  accompanied  by  slow  recovery  or  followed  by  chronic 
meningitis.     Death  may  occur  very  early  from  exhaustion. 

Diagnosis. — Injury,  or  childbirth  followed  by  the  sudden  onset 
of  attack,  with  irritative  symptoms,  as  pain,  which  suddenly  sub- 
side, point  to  extradural  haemorrhage.  In  hgematomyelia  there 
is  less  pain  and  irritation,  but  more  marked  paralysis  and  anaes- 
thesia. This  is  also  true  of  crush  of  the  cord  from  fracture  or 
dislocation.  In  tetanus  the  symptoms  are  more  gradual  in  onset 
and  trismus  is  present. 

Prognosis. — If  the  patient  survives  beyond  the  fifth  day  there 
is  a  chance  for  partial  or  complete  recovery.  Usually  the  prog- 
nosis is  most  grave,  the  patient  succumbing  within  a  few  days. 

Treatment  consists  of  absolute .  rest  in  bed,  administration  of 
sedatives  and  drugs  to  move  the  bowels  and  relieve  pain.  Local  de- 
pletion may  be  tried,  as  by  means  of  wet  cups  over  the  supposed 
site  of  lesion.  The  use  of  styptics,  as  suprarenal  extract  or  min- 
eral acids,  may  be  of  service  in  the  purpuric  cases.  The  sorbe- 
facient  effect  of  the  iodides  may  be  tried  later;  also  the  use  of 
mercury.  In  chronic  cases  counter-irritation  over  the  spine  on 
alternate  days  for  a  fortnight  may  prove  of  value-  by  its  alterative 
action. 

(2)  Hsematomyelia. — Heemorrhage  into  the  substance  of  the 
cord. 

Etiology. — This  is  not  unusual.  It  may  be  due  to  vascular 
diseases  or  purpura  hsemorrhagica,  or  may  be  secondary  to  tumours 
or  to  myelitis.  Primary  haemorrhage  occasionally  occurs  in  in- 
fancy, but  it  is  usually  found  in  males  in  early  adult  life.  Accord- 
ing to  Gowers,  excessive  coitus  is  a  potent  cause,  as  are  injuries,  ex- 
posure, overexertion,  syphilitic  endarteritis,  or  convulsive  seizures, 


246  TEEATISE    OX    XERYOUS    DISEASES 

which  latter  may  also  be  the  cause  of  hasmorrhage  into  the  skin  and 
intermuscular  connective  tissue.  Hsematomyelia  may  occur  in  old 
people  with  arteriosclerosis^  spinal  apoplexy  being  produced,  in- 
stead of  cerebral  haemorrhage. 

Symptoms  develop  rapidly,  with  numbness  or  weakness  for  a 
few  hours.  Then  sudden  paraplegia,  or  ataxia,  or  both.  Often 
"the  anaesthesia  is  dissociated — there  being  a  loss  of  pain  or  ther- 
mic sense,  with  the  retention  of  touch  sense.  The  urine  may 
have  to  be  drawn  on  account  of  paralysis  of  the  sphincters.  The 
reflexes  may  at  first  be  absent,  but  soon  return  and  become  exag- 
gerated. There  is  much  pain  in  the  back,  and  if  the  lesion  is 
high  up  the  anus  and  thorax  are  involved.  The  acute  symptoms 
will  have  subsided  within  a  fortnight,  when  the  case  becomes 
practically  one  of  chronic  myelitis.  If  improvement  has  not  oc- 
curred, the  symptoms  will  instead  take  on  the  character  of  acute 
myelitis,  and  death  will  soon  follow. 

Pathology. — The  blood-vessels  diseased  are  those  of  the  gray 
matter,  which  are  in  the  ventral  cord  and  under  considerable  ten- 
sion. The  rupture  of  these  vessels  is  due  to  fatty  degeneration 
or  to  specific  endarteritis.  ]\Iiliary  aneurysms  are  rare  in  the  cord, 
such  as  not  infrequently  develop  in  the  brain.  Hsemorrhage  may 
be  the  cause  or  the  result  of  a  myelitis.  In  the  former  case  the 
clot  may  be  absorbed,  leaving  a  cavity  as  in  the  cord;  or  broken- 
down  tissue  may  become  the  central  foci  of  a  myelitis.  The  hsemor- 
rhage is  usually  single ;  it  may  be  multiple.  It  is  likely  that  cases 
of  disseminated  myelitis  following  infectious  fevers  are  due  to 
multiple  ecchymoses.  The  bleeding  at  times  is  the  result  of  new 
growth,  as  in  syringom3'elia. 

Diagnosis. — Sudden  onset  without  any  long  premonitory 
symptoms  and  the  absence  of  fever  followed  by  gradual  improve- 
ment are  characteristic  of  spinal  hcemorrJiage.  There  is  much  less 
pain  than  in  meningeal  licemorrliage,  while  the  dissociation  of 
cutaneous  sensation  is  very  characteristic.  In  acute  softening 
there  is  less  of  the  dissociation  of  sensation,  but  a  more  extensive 
paralysis.  The  latter  may  be  mistaken  for  acute  primary  myelitis, 
which  does  often  follow.  Meningeal  haemorrhage  is  usually  more 
painful,  and  there  is  less  paralysis,  more  spasm,  and  a  more  com- 
plete recovery  afterward. 

Prognosis. — This  is  often  serious  as  regards  life,  and  it  is 
dubious  as  to  recovery  of  power.     Both  much   de]:iend   on  the 


DISEASES    OF    THE    SPIRAL    CORD  247 

extent  and  seat  of  the  haemorrhages.     Dorsal  hsemorrhages   are 
more  favourable,  cervical  the  least. 

Treatment. — Cold  to  the  spine,  such  as  through  ice-bags,  asso- 
ciated with  absolute  rest,  together  with  small  doses  of  cardiac  de- 
pressants, as  aconite,  can  be  tried.  Treatment  must  be  prompt 
if  any  good  is  at  all  to  be  done.  The  after-treatment  is  entirely 
symptomatic,  and  later  it  is  for  the  myelitis  that  may  follow  as  a 
seciuela  (see  Myelitis). 


SYRINGOMYELIA 

Is  an  affection  of  the  spinal  cord,  which,  while  not  more  rare 
than  disseminated  sclerosis,  has  only  been  in  recent  years  brought 
to  full  light.  The  disease  was  first  accurately  described  by 
Sehultze  in  1886 ;  since  that  time  there  have  been  some  hundred 
cases  reported  in  the  literature,  and  in  the  light  of  the  pathological 
findings  undoubtedly  many  obscure  cases  of  cord  disease  reported 
in  the  past  have  been  of  this  nature. 

There  are  two  varieties  of  dilatation  of  the  spinal  cord:  First, 
hydromyelia,  which  is  a  dilatation  of  the  central  canal,  this  being 
lined  by  the  normal  columnar  epithelium.  This  condition  may 
give  rise  to  the  symptoms  of  syringomyelia  proper,  similar  to  the 
second  type,  where  the  cavity  occurs  within  the  gray  matter  of  the 
cord,  but,  as  a  rule,  is  separated  from  the  central  canal.  A  cavity 
or  cavities  in  this  instance  are  the  result  of  softening  areas  in  glio- 
matosis  in  the  gray  cord.  The  latter  condition  is  probably  hered- 
itary, being  an  unnatural  excess  in  development  and  continuance 
of  the  formation  of  this  embryological  tissue.  The  cavities  may 
be  single,  multiple,  or  consist  of  numerous  dilatations  connected 
by  irregular  and  deviating  sinuses;  so  that  one  opening  may  be 
in  this  manner  connected  with  another  at  a  distance  longitudinally 
from  the  first  one.  One-half  the  cord  may  be  involved  alone,  or 
be  at  least  more  diseased  than  the  other  half.  The  cervico-dorsal 
cord  is  the  most  frequent  site  of  the  disease ;  although  the  medulla 
and  pons,  or  lumbar  and  sacral  cord,  may  be  involved.  That  the 
disease  has  occurred  following  the  infectious  fevers  does  not 
particularly  sliow  them  to  be  causative  of  the  malady;  so 
that  the  hereditary  feature  is  the  principal  point  in  astiology,  as 
alroadv  indicated. 


248 


TREATISE    ON    NEEVOUS    DISEASES 


Symptomatology. — Four  distinctive  types  of  symptoms  exist  in 
certain  groups  of  cases  of  syringomyelia,  viz. : 

1.  The  ordinary  type  described  above. 

2.  Motor  type,  resembling  amyotrophic  lateral  sclerosis. 

3.  Sensory  type,  in  which  disturbances  of  sensation,  particu- 
larly loss  of  thermic  sense  due  to  disease  in  Glower's  tract,  are 
prominent  features.  It  may  be  hemiplegic  in  distribution,  or  in 
irregular  areas. 

4.  Those  cases  with  pronounced  tro]3hic  changes,  painful  whit- 
lows, etc.,  as  described, by  Schlesinger  in  1895. 

The  disease  may  re- 
semble a  number  of 
chronic  cord  diseases 
in  its  clinical  aspect,  de- 
pending upon  the  im- 
pingement of  the  de- 
structive lesion  in  vari- 
ous anatomico-physio- 
logical  centres  and 
tracts.  Thus  syringo- 
myelia may  resemble 
tabes  of  an  irregular 
type  when  the  posterior 
columns  of  the  white 
matter  are  invaded,  or  it 
may  present  particularly 
.he  picture  of  progressive 
muscular  atrophy  of  spinal  origin  if  the  dilatation  occurs  towards 
the  anterior  horns  of  the  gray  matter.  In  rare  cases  the  disease 
may  simulate  spastic  paralysis  due  to  irritation  of  the  lateral  col- 
umns of  the  spinal  cord;  or  in  the  rarest  cases  it  may  simulate  in- 
sular sclerosis.  So  that  given  a  case  of  chronic  spinal  cord  disease 
of  atypical  or  irregular  manifestations,  syringomyelia  must  be 
thought  of.  The  particular  symptom  of  diagnostic  import  is  the 
dissociation  of  sensory  phenomena — for  example,  there  is  usually 
loss  of  pain  and  temperature  sense  in  irregular  areas  (analgesia 
and  thermo-ansesthesia),  with  preservation  of  the  sense  of  touch 
and  muscle  sense.  If  the  cavity  is  on  one  side  of  the  cord  alone, 
and  is  of  considerable  size,  we  may  have  symptoms  of  Brown- 
Sequard  paralysis,  to  be  told  from  the  usual  type  of  "crossed 


Pig.  59. — Atrophy  of  Intrinsic  Muscles  of 
THE  Hand  and  Thermo-An^sthesia  in 
A  Case  of  Syringomyelia.  (Philadelphia 
Hospital.) 


DISEASES    OF    THE    SPINAL    COED  249 

paralysis  "  of  this  sort  by  the  absence  of  pain  and  temperature  sense 
rather  than  the  touch  and  muscular  sense,  as  indicated;  or  as  in 
spinal  tumour  or  unilateral  sclerosis,  ansesthesia  would  be  the  sen- 
sory manifestation  more  particularly,  or  all  forms  of  sensation 
would  be  absent.  In  cases  where  the  cervical  cord  is  affected  high 
up  the  ascending  branch  of  the  fifth  nerve  may  be  affected,  produ- 
cing anaesthesia  of  the  face.  From  involvement  of  the  cervical  sym- 
pathetic, the  pupil  on  the  affected  side  may  be  contracted,  and  there 
may  be  an  absence  of  sweating  on  the  same  side  of  the  face.  Lordo- 
sis or  scoliosis  may  occur  in  cases  where  the  spinal  centres  govern- 
ing the  muscles  of  the  spinal  column  are  destroyed,  this  permitting 
muscular  atrophies  and  consequent  spinal  curvature.  In  some  cases 
motor  cells  of  the  spinal  column  are  destroyed,  permitting  mus- 
cular atrophies  and  consequent  spinal  curvature.  In  many  cases 
there  is  absence  of  the  deep  reflexes  in  the  upper  extremities;  or  if 
the  disease  descends  low  enough  the  knee-jerk  may  be  absent — 
all  depending  upon  destruction  of  the  posterior  roots  of  the 
spinal  cord.  The  atrophy  may  extend  to  the  lower  extremities, 
and  there  may  be  reaction  of  degeneration  found  in  the  affected 
muscles.  The  course  of  the  disease  is  slow,  and  may  at  any  time 
come  to  a  standstill.  There  may  be  remissions  in  the  clinical 
course,  no  doubt  due  to  extension  of  the  process  being  abated. 
The  patient  may  die  from  involvement  of  the  cardio-respiratory 
centres  in  the  medulla. 

Treatment  of  this  affection  is  of  little  value,  although  gen- 
eral hygienic  measures  to  control  the  circulation  by  means  of 
proper  woollen  clothing  and  the  protection  of  the  individual 
against  inclement  weather  is  to  be  instituted.  Such  patients 
should  live  an  inactive  life  in  the  open  air  and  sunshine.  Contin- 
uous doses  of  iodide  of  potash  may  do  good  in  the  minority  of 
cases  through  the  alterative  and  sorbefacient  effects  of  the  drug. 
Ee-education  by  exercises  will  prove  of  value  where  ataxia  exists. 
Massage  and  static  electricity  may  aid  nutrition,  better  the  cir- 
culation, and  assist  in  staying  the  muscular  wasting  and  sensory 
changes. 


350  TEEATISE    ON    NEEVOUS    DISEASES 

MUSCULAR    DYSTROPHIES 

These  are  classed  under  diseases  of  the  nervous  system, 
although  no  constant  pathological  finding  has  been  found  in  the 
nervous  sj^stem.  Palsy  is,  however,  a  constant  neurological  symp- 
tom of  all  of  them.  There  are  three  forms  of  muscular  dystrophies, 
so  called : 

1.  Pseudo-hypertrophic  paralysis  (Duchenne). 

2.  Idiopathic  muscular  atrophy. 

3.  ISTeuritic  form  of  muscular  atrophy  (Charcot-Marie-Tooth). 

(1)  Pseudo-hypertrophic  Paralysis. — The  first,  a  disease  begin- 
ning in  early  childhood,  is  a  family  type  of  disorder,  although  not 
known  to  be  directly  hereditary.  The  progenitors  of  the  patient 
will  be  found  to  be  alcoholics,  subjects  of  syphilis,  or  some  other 
form  of  degenerative  disease.  This  has  been  satisfactorily  proved 
to  us  in  investigations  made  by  Wharton  Sinkler  and  the  writer 
in  a  statistical  study  made  in  the  Infirmary  of  Nervous  Diseases 
of  Philadelphia  in  1899. ^ 

Males  are  more  frequently  affected,  and  several  in  the  family 
may  be  picked  out,  others  escaping.  The  age  limit  of  five  to  ten 
is  the  most  usual  time  of  onset.  The  patient  first  complains  of 
feebleness  in  progression,  and  it  will  be  noted  that  there  is  slight 
toe-drop,  that  the  calves  of  the  legs  are  enlarged,  which  greatly 
increase,  causing  a  sense  of  firmness  to  palpation.  Other  points 
of  pseudo-hypertrophy  may  exist  in  the  pectoral  muscles,  the  del- 
toids, and  about  the  shoulder-girdle.  With  the  enlargement  comes 
on  an  increasing  weakness  of  the  muscles  involved  (Fig.  60).  An 
early  and  characteristic  feature  is  difficulty  in  arising  from  a 
supine  position.  The  patient  contorts  the  trunk  in  the  endeavour 
to  aid  the  specially  weakened  extremities,  beginning  by  pushing  the 
body  up  with  the  hands  upon  the  thighs,  then  forcing  the  trunk  to 
the  vertical,  thus  extending  the  trunk  upon  the  thighs,  then  draw- 
ing the  lower  extremities  into  the  erect  posture.  The  characteristic 
attitude  is  the  hand-over-hand  method  in  pushing  up  the  trunk 
with  the  arms,  in  bringing  the  body  to  the  erect  position.  This 
characteristic  sign  of  the  paresis  may  last  for  many  months. 
There  is  no  true  ataxia,  however.  The  patient  is  seen  to  have 
difficulty  in  mounting  steps,  and  will  frequently  trip  over  slight 

'  -Tournal  of  American  Medical  Association,  November,  1899,  Family  Dis- 
eases. 


DISEASES    OF    THE    SPINAL    COED 


251 


elevations  on  the  surface.  Finally  the  patient  cannot  rise  from 
the  sitting  position,  and  it  will  then  be  found  that  the^  muscles, 
which  were  apparently  enlarged,  have  atrophied  down  to  the  nor- 
mal size  perhaps,  or  beyond  this,  and  are  board-like  to  the  sense 
of  touch.  Other  muscles  may  pass  directly  into  atrophy  without 
any  pre-existent  enlargement. 

Reflexes. — The  deep  reflexes  will  be  found  lessened  or  absent 


2  3 

Pig.  60. — Pseudohypertrophic  Paralysis  showing  Atrophy  of  Shoulder, 
Girdle,  and  Thighs  ;  also  Manner  of  Rising  in  the  Order  1,  2,  3. 
(Medico-Chirurgical  Hospital. ) 

and  the  superficial  reflexes  diminished.  The  end  picture  in  this 
malady  is  of  extreme  muscular  atrophy  and  absolute  helplessness. 
Coldness  of  the  extremities,  cyanosis,  enfeebled  heart  action,  and 
general  lessening  of  the  functionation  of  the  special  senses  with 
mental  deterioration,  occurs  later  in  the  affection,  with  dribbling 
of  saliva  from  mouth,  difficulty  in  swallowing,  etc.     The  average 


252,  TBEATISE    ON    NEEVOUS    DISEASES 

duration  of  the  disease  is  from  one  to  twenty  years,  yet  depending 
much  upon  the  preserved  nutrition  and  vegetative  function  of  the 
patient;  also  upon  his  immunity  or  the  absence  of  any  of  the 
complicating  infectious  diseases,  which  are  particularly  fatal  in 
them.  If  not  carried  off  by  intercurrent  disease,  the  patient  may 
die  of  heart  failure,  from  involvement  of  that  organ. 

Pathology. — This  consists  of  excessive  deposit  of  fat  cells 
within  the  sarcolemma,  and  fatty  change  and  swelling,  loss  of 
striation  of  the  muscle  cells.  Overgrowth  of  connective  tissue 
also  takes  place  between  the  muscle  cells.  As  the  disease  progresses 
the  disappearance  of  the  fat  cells  takes  place,  connective-tissue 
growth  predominates,  and  the  muscle  substance  is  degenerated, 
leaving  debris  and  connective  tissue  instead. 

Diagnosis.^This  should  not  be  confounded  with  any  other 
disease.    In  neuritis  there  is  pain  and  tenderness  of  nerve  trunks. 

Pro  gliosis. — An  incurable  malady.  There  may  be  prolonged 
remissions. 

Treatment. — Much  can  be  done  to  stay  the  progress  of  the  dys- 
trophy. This  consists  in  persistent,  scientific  use  of  massage  to 
favour  better  circulation,  as  well  as  of  the  elimination  of  the 
products  of  catabolism,  and  to  prevent  retrograde  change  in  the 
muscle  cells.  Nutritious  diet,  consisting  of  eggs,  red  meats,  or 
any  other  nutritious  proteids,  is  indicated.  Vegetables  containing 
iron  are  valuable  in  this  disease,  in  which  metabolism  is  so  per- 
verted. In  spinach  iron  can  be  introduced  into  the  blood  Avith 
least  gastric  disturbance.  The  overdistention  of  the  stomach  with 
carbohydrates  is  most  certain  to  do  harm.  Predigested  foods,  as 
beef,  is  only  called  for  when  the  stomach  absolutely  refuses  to  digest 
the  more  ordinary  foodstuffs  suggested.  Electricity  does  not  aid 
us  much,  although  the  static  breeze  may  be  of  value  in  stimulating 
the  circulation  at  the  periphery,  and  to  the  carrying  off  of  the  waste 
products.  The  hypophosphites,  phosphorus,  and  strychnine  as  a 
nerve  tonic  are  all  of  value  in  this  chronic  disorder.  Such  patients 
should  be  carefully  protected  from  cold  and  dampness,  and  given 
plenty  of  fresh  air  and  sunlight,  in  a  stimulating  climate,  at  low 
altitudes.    Sea  air  is  particularly  bracing. 

(2)  Idiopathic  muscidar  atrophy  is  of  two  types:  (a)  the 
fascio-scapulo-humeral  t^^pe  (Landouzy-Dejerine),  and  (h)  the 
juvenile  form  of  Erb. 

(a)  In  the  former  the  atrophy  begins  in  the  orbicularis  oris  and 


Fig.  61.— Progressive  Muscular  Atrophy  of  Spinal  Origin  (Anterior  Pol- 
iomyelitis Chronica)  showing  Wrist-Drop,  Atrophy  of  Hand  Muscles, 
AND  of  Shoulder  Girdle,  and  the  Pectoral  Muscles.  (Medico-Chirur- 
gical  Hospital.) 


254  -  TREATISE   ON   NERVOUS   DISEASES 

the  face,  producing  the  hollow-cheek  appearance,  the  so-called 
"  tapir  month,"  and  accompanied  by  fibrillar}^  twitching  of  the 
mnscles  involved.  This  atrophy  progresses  in  the  trapezius  and 
deltoid  muscles,  upper  part  of  the  arms,  until  within  six  months 
or  a  year  there  is  a  very  marked  physical  change  in  the  appearance 
of  the  upper  portion  of  the  body.  The  patient  is  unable  to  adduct 
or  abduct  the  extremities,  and  particularly  to  raise  the  arms  on 
a  level  with  shoulder.  Finally,  the  atrophy  extends  to  the  lower 
part  of  the  arm  and  interosseous  muscles,  the  lower  extremities 
becoming  involved  last,  if  at  all,  in  proportion  with  the  duration  of 
the  case. 

(&)  The  juvenile  form  begins  in  the  interosseous  muscles  of 
the  upper  extremities,  the  thenar  and  hypothenar  eminences,  ex- 
tending to  the  upper  arm,  finally  to  the  lower  extremities — 
thighs  and  legs — the  patient's  progression  being  with  feebleness 
and  evident  toe-drop.  This  occurs  most  frequently  between  the 
ages  of  twelve  and  sixteen.  It  is  very  slow  in  progression,  the  pa- 
tient living  for  many  years.  The  vaso-motor  weakness  is  shown  by 
coldness  and  clamminess  of  the  extremities,  the  indurated  condition 
of  the  skin,  brittle  nails,  etc.  The  deep  reflexes  are  abolished 
early,  but  there  is  no  reaction  of  degeneration,  except  in  rare  in- 
stances, very  late  in  the  course  of  the  disease  and  where  particu- 
larly large  bundles  of  fibres  are  affected  in  the  muscle  atrophy. 

The  sub-type  known  as  progressive  muscular  atrophy  of  spinal 
origin  has  a  similar  symptomatology,  but  begins  in  early  adult  life. 
This  is  the  so-called  poliomyelitis  chronica.  At  times  there  is 
pain,  the  marked  feature  being  fibrillary  contractions,  also  that 
it  occurs  later  in  life  than  the  muscular  dystrophies  proper,  and 
that  in  the  pathology  of  the  disease,  in  addition  to  atrophy  of  the 
muscle  cells  and  overgrowth  of  connective  tissue,  there  is  a  degen- 
eration of  the  multipolar  cells  in  the  anterior  cornu  of  the  gray 
matter  of  the  cord. 

(3)  The  so-called  neuritic  type  is  that  which  begins  in  the 
perineal  muscles,  producing  peculiar  guttering  in  the  perineal 
region  of  the  legs,  with  infrequently  a  toe-drop,  and  the  process 
gradually  extending  up  the  thighs,  and  finally  affecting  the  gen- 
eral musculature. 

Pathology.— T\ie  pathology  of  this  affection  is  not  known  fur- 
ther than  the  involvement  of  the  muscles  in  atrophy  and  over- 
growth of  connective  tissue. 


DISEASES    OF    THE    SPINAL    CORD  255 

Treatment. — In  all  these  difEerent  forms  of  muscular  atrophy  it 
is  largely  symptomatic.  Mechanical  stimulation  of  the  muscles 
directly  by  means  of  massage,  Swedish  .movements,  or  galvanism 
are  to  be  assiduously  applied.  Static  electricity  is  a  valuable 
agent  to  promote  nutrition  and  bettered  circulation  in  the  tissues. 
The  orthopaedist  should  be  consulted  in  many  of  these  cases  in 
order  to  prevent  deformities  as  well  as  to  strengthen  joints  en- 
feebled by  the  muscular  disease,  thus  making  life  more  useful 
in  these  patients,  who  might  otherwise  be  prematurely  crippled. 
The  hypophosphites  and  cod-liver  oil,  plus  a  nutritious  diet,  con- 
sisting largely  of  proteids,  with  the  use  of  eliminants,  as  copious 
draughts  of  water,  the  various  mineral  waters  being  particularly 
adaptable,  are  all  agents  of  vital  importance.  Much  can  be  done 
for  these  patients  in  the  way  of  alleviation  by  persistent  endeavour, 
even  though  cure  is  not  established.  Strychnine  is  of  value  in 
fairly  large  dosage — gr.  j\  to  j\  t.  i.  d. 


ANTERIOR    POLIOMYELITIS   ACUTA   OR 
INFANTILE    PARALYSIS 

This  is  a  disease  of  sudden  onset,  more  frequently  seen  in  child- 
hood, and  is  probably  of  microbic  nature.  The  disease  is  fulminat- 
ing, and  is,  as  a  rule,  ushered  in  by  a  chill,  followed  by  hyperpy- 
rexia (104°  F.  or  more),  accompanied  by  nausea  and  vomiting  and 
general  restlessness.  With  these  there  may  be  hypersesthesia  and 
sensitiveness  of  one  or  more  extremities.  The  fever  lasts  from 
several  to  forty-eight  hours,  as  the  case  may  be,  when  it  will  abate 
and  the  patient  be  left  in  a  generally  weakened  condition,  with 
palsy  of  one  lower  extremity,  as  a  rule.  Rapid  wasting  will  super- 
vene in  the  paralyzed  part,  and  at  the  end  of  ten  da5rs  or  two 
weeks  reaction  of  degeneration  will  be  found  in  the  paralyzed  mus- 
cles. One  lower  extremity  is  generally  involved,  and  the  anterior 
tibial  group  more  than  other  muscles,  the  next  in  frequency  being 
the  calf,  the  extensor  femori,  and  the  adductor  muscles.  Rarely 
an  upper  extremity  is  alone  affected.  There  will  be  found  an 
absence  of  the  deep  reflexes;  as  a  rule  the  knee-jerk  is  wanting 
where  the  lower  extremity  is  involved.  The  limb  becomes  cold, 
clammy,  cyanosed,  and  wasted.  If  thg  member  is  not  totally  para- 
lyzed, the  patient  will  be  able  to  limp  about,  and  contractures,  de- 
formities of  the  limb,  such  as  acquired  clubfoot,  occur  later.    The 


256  TEEATISE    OK    KERVOUS    DISEASES 

disease  A^ery  seldom  extends  to  other  parts  of  the  cord  after  the 
original  attack;  the  patient  generally  recovers  full  and  usual 
health.  The  paralyzed  extremity  does  not  grow  in  length  as  do 
the  others^  and  in  consequence  of  the  shortened  limb  there  may  be 
a  spinal  curvature  as  a  remote  consequence.  The  sphincters  are 
never  involved  in  the  acute  attack  of  infantile  paralysis.  Decubitus 
seldom  results.  The  symptom  of  "  palsy  "  is  at  first  rather  rapid 
in  its  partial  recovery,  then  promptly  progressive.  In  some  cases 
the  deep  reflexes  are  retained  or  increased.  It  may  occur  in  epi- 
demic form  in  spring  and  summer. 

Pathologij. — This  consists  of  acute  inflammation  of  the  multi- 
polar cells  in  the  anterior  horns  of  the  gray  matter  of  the  cord;, 
usually  in  the  dorso-lumbar  region.  Following  the  inflammation 
there  is  found  a  degeneration  of  the  multipolar  cells,  overgrowth 
of  connective  tissue,  and  molecular  debris ;  also  degeneration  of  the 
nerves  coming  from  this  particular  segment  of  the  cord,  with 
atrophy  and  fatty  degeneration  of  the  muscles  supplied  by  them. 

Diagnosis. — In  neuritis  there  is  tenderness  of  the  nerve-trunks, 
and  as  a  rule  it  is  less  sudden  in  onset,  with  less  severe  palsy,  though 
a  more  general  and  constantly  progressive  or  regressive  paralysis. 

Some  cases  of  hip-joint  disease  may  simulate  infantile  palsy 
only  in  inability  to  move  the  extremity.  The  hip-joint  would  be 
partially  ankylosed  in  eoxalgia.  The  pseudo-palsy  of  rickets  is 
always  associated  with  that  disease  and  there  is  little  wasting  and 
no  history  of  an  '''attack.'^     The  knee-jerk  is  capricious. 

Pseudo-muscular  atrophy  or  other  local  forms  of  dystrophies 
need  but  to  be  mentioned;  as  well  as  the  cerebral  palsies  of  child- 
hood, which  latter  are  associated  with  spasticity;  while  the  former 
are  gradual  in  onset  and  widespread. 

Prognosis. — This  depends  entirely  upon  the  degree  and  extent 
of  involvement  of  the  gray  matter  of  the  cord.  An  attack  very 
seldom  kills.  If  a  few  muscle-bands  are  affected,  it  is  possible  that 
almost  complete  recovery  may  occur  with  time  and  proper  treat- 
ment. Where  one  member  is  markedly  paralyzed  usually  consider- 
able power  will  be  restored  within  a  few  months'  time,  when  fur- 
ther recovery  of  the  individual  muscles  will  seldom  take  place. 

Treatment. — This  consists  in  the  management  of  the  attack, 
which  would  be  as  of  an  ordinary  acute  infection,  treating  the 
hyperpyrexia,  giving  a  calomel  purge,  and  protecting  the  affected 
limb  by  carefully  bandaging  in  cotton.    After  the  acute  stage  has 


DISEASES    OF    THE    SPIXAL    CORD  257 

subsided,  the  general  nutrition  of  the  patient  should  be  looked 
after.  The  use  of  the  hypophosphites  and  a  careful  dietary  are 
important,  the  remainder  of  the  treatment  being  entirely  local. 
This  consists  in  massage  and  galvanism  to  the  paralyzed  muscles, 
continued  for  months  or  years,  depending  upon  the  severity  of  the 
ease.  If  the  child  is  able  and  there  is  no  tendency  to  deformity, 
it  can  walk  about;  or  if  there  be  a  tendency  to  deformity,  the 
orthopgedist  should  be  consulted  with  the  hope  of  "  bracing  "  the 
weakened  limb  to  prevent  deformity  that  may  occur  in  such  cases. 
A  high  shoe  may  be  necessary  for  the  paralyzed  limb  where  there 
is  marked  slowness  of  growth  in  it.  The  use  of  strychnine  is  of 
value,  and  should  be  given  in  doses  according  to  the  age,  over 
prolonged  periods  of  time.  In  inclement  weather  these  patients 
should  always  be  well  clothed.  They  should  be  especially  well 
protected  against  cold  of  winter  and  sequent  frost-bite. 

In  eases  where  there  is  very  little  power  remaining  in  an  ex- 
tremit}^,  a  method  of  assisting  the  exercise  of  the  muscles  is  by 
daily  immersing  the  child  in  a  warm  bath  and  permitting  him  to 
"  float "  the  affected  limb  about  in  the  water.  The  weight  of  the 
water  displaced  by  the  member  will  be  just  that  amount  of  relief 
of  dead  weight  in  attempted  exercising.  I  have  seen  great  good 
from  this  method  of  treatment  in  one  case. 

GLOSSO-LABIO-PHARYNGEAL    PALSY,    OR    BULBAR 

PARALYSIS 

Bulbar  paralysis  applies  to  a  number  of  systematized  symp- 
toms, due  to  diseases  or  lack  of  functionation  in  the  centres  in 
the  bulb  or  oblongata  (fifth,  seventh,  ninth,  tenth,  eleventh,  and 
twelfth  cranial  nerves),  and  is  divided  into  several  varieties:  (1) 
acute,  (2)  chronic,  (3)  asthenic,  and  (4)  pseudo. 

Symptoms. — These  may  accompany  other  diseases,  such  as 
amyotrophic  lateral  sclerosis,  etc. 

(1)  The  symptoms  of  acute  hulhar  paralysis  are  a  sudden 
onset,  dribbling  of  saliva,  with  the  motor  difficulty  (dysarthria)  of 
speech,  and  atrophy  of  the  tongue.  This  acute  form  may  be 
ushered  in  by  an  apoplectiform  attack.  It  is  also  known  as  polio- 
encephalitis inferior.  The  symptoms  are  rapidly  progressive,  the 
patient  losing  the  power  to  swallow.  With  the  dysphagia  there 
is  loss  of  flesh.  The  patient  is  the  subject  of  choking  spells  on 
attempting  to  swallow  either  solids  or,  in  bad  cases,  liquids.  In 
17 


258  TREATISE    ON    NERVOUS    DISEASES. 

this  affection  the  patient  is  perfectly  conscious,  bnt  at  times  it  is  a 
cTifficnlt  matter  to  determine  whether  the  mind  is  affected  or  not, 
owing  to  the  motor  difficulty  of  speech.  The  latter  is  of  a  drawling 
nature^  the  words  being  prolonged,  the  consonants  first  being 
affected ;  finally  the  inability  to  pronounce  words  of  more  than,  one 
syllable  with  any  degree  of  distinctness.  The  patient,  however, 
is  able  to  write  perfectly  well.  With  this  added  fact,  bulbar  paral- 
ysis is  easily  diagnosed  from  any  form  of  aphasia. 

The  course  of  the  disease  is  very  rapid,  and  within  three  or 
four  months'  time  the  patient  is  in  a  very  serious  condition.  Death 
is  frequently  caused  by  an  inspiration  pneumonia,  or  a  sudden 
attack  of  choking;  or  from  respiratory  or  heart  failure,  due  to  the 
involvement  of  the  vagi  centres. 

(2)  The  chronic  type  of  bulbar  paralysis  is  much  slower  in 
its  progress.  The  symptoms — stuttering,  dysphagia,  regurgitation 
of  liquids  from  the  nose-  on  attempting  to  swallow — being  more 
gradual  in  progress.  The  patient  otherwise  keeps  in  fairly  good 
health,  since  the  slowness  of  the  process  does  not  deprive  him  from 
getting  ample  nourishment  until  late  in  the  course  of  the  disease. 
The  main  difference  between  this  and  the  acute  form  of  the  dis- 
ease lies  in  the  rapid  progress  of  the  latter,  accompanied  by 
general  wasting,  and  the  slower  progress  of  the  former. 

The  pathology  of  these  forms  is  different  in  that  in  the  acute 
types  there  is  inflammation,  a  softening  process,  or  minute  haem- 
orrhages into  the  bulbo  pons  and  cord,  while  the  symptoms  are 
apt  to  be  consistently  bilateral  from  the  first;  whereas  in  the 
chronic  form,  which  is  due  to  atrophy  of  the  motor  neurones,  there 
is  simply  an  aggression  of  the  symptoms  of  one  side  out  of  propor- 
tion to  the  other,  although  both  are  involved.  The  duration  of 
the  chronic  type  is  from  eighteen  months  to  three  years.  The 
patient  may  suffer  from  irregular  cardiac  action  and  attacks  of 
tachycardia.  It  is  somewhat  singular  that  heart  failure  does  not 
occur  more  frequently  at  the  very  onset  of  the  disease,  because  of 
the  involvement  of  the  vagus  centre. 

The  prognosis  of  both  of  the  above  forms  is  unpromising. 
Results  of  treatment  may  but  ameliorate. 

The  treatment  is  more  palliative  than  anything  else,  but  con- 
siderable can  be  done  in  chronic  cases  to  alleviate  suffering  by 
a  careful  attention  to  the  manner  of  food  administration,  the  use 
of  the   stomach-tube   being   a   valuable   method    of   feeding   the 


DISEASES    OF    THE    SPINAL    CORD  259 

patient.  This  should  be  done  at  regular  intervals  during  the 
course  of  the  disease,  even  when  the  patient  can  swallow  only  a 
small  amount,  since  in  this  there  is  liability  to  "inspiration" 
pneumonia.  The  use  of  strychnine  in  fairly  large  doses  ( -gV  to  ^-^ 
of  a  grain,  t.  i.  d.)  is  of  great  value.  The  patient  should  live  a  very 
quiet  life.  Galvanism  to  the  throat  muscles  is  of  value.  Treat- 
ment of  complications,  such  as  pneumonia,  is  medical  detail  that 
need  not  be  given  here. 

(3)  The  astliefiic  form  of  bulbar  paralysis  occurs  later  in  life 
than  the  organic  forms,  and  is  more  frequent  in  women  than  in 
men,  occurring  about  the  age  of  forty.  It  is  designated  asthenic 
because  no  definite  lesion  has  as  yet  been  determined,  there  being 
asthenia  of  the  throat  muscles. 

The  pathology  is  very  like  an  auto-intoxication  due  to  deficiency 
of  metabolism,  weakening  the  bulbar  centres.  The  muscles  sup- 
plied by  the  motor  cranial  nerves  are  involved ;  the  centres  are  not 
able  to  generate  or  transmute  nervous  energy.  Besides  the  symp- 
toms already  rehearsed  other  characteristic  features  of  this  form 
of  disease  are  the  remissions  which  recur  in  it  regularly  from  time 
to  time.  Thus  a  patient  may  be  unable  to  speak  save  in  a  whisper 
or  in  very  indistinct  monosyllables  for  a  week  or  ten  days,  bodily 
weakness  being  present  at  the  same  time,  and  within  a  fortnight 
the  voice  may  have  returned,  the  patient  having  become  much 
brighter  mentally,  and  physically  stronger. 

Prognosis. — This  is  not  good  as  to  recovery,  but  the  patient 
may  live  for  many  years  in  comparative  comfort  between  the 
attacks,  although  harassed  at  frequent  intervals  by  aggression 
of  the  symptoms.  I  have  had  the  pleasure  of  observing  a  case  of 
this  sort  with  Dr.  Wharton  Sinkler  at  the  OrthopEedic  Hospital 
for  some  three  or  four  years. 

(4)  Pseudo-huTbar  palsy  is  a  type  of  progressive  failure  of 
the  glosso-lahio-pharyngeal  muscles  unassociated  by  atrophy  of 
muscles  or  general  weakness. 

The  lesion  is  very  likely  cerebral,  affecting  the  upper  motor  neu- 
rones of  the  motor  cranial  nerves,  particularly  the  ninth  and  tenth. 

Treatment  of  pseudo  and  asthenic  bulbar  palsies  does  not  differ 
from  that  of  the  chronic  type.  Good  food,  out-of-door  life,  arsenic, 
strychnine,  the  hypophosphites  and  glycerophosphates  being  of 
importance;  also  the  use  of  gavage. 


260  TEEATISE    ON    NERVOUS    DISEASES 

THE    COMBINED    SCLEROSES 

By  the  combined  scleroses  is  meant  those  forms  of  degeneration 
in  which  both  the  lateral  and  the  posterior  columns  are  ajffected. 
Westphal  first  described  the  condition  in  1867.  There  are  several 
types : 

(1)  Hereditary  spinal  ataxia  (Friedreich's  disease  and  hered- 
itary ataxic  paraplegia). 

(2)  Combined  sclerosis  in  anaemic  and  toxic  states  (Putnam 
and  Dana  type). 

(3)  Combined  sclerosis  complicating  general  paresis. 

(4)  Accidental  forms,  as  Gowers's  ataxic  paraplegia. 

The  clinical  pictures  of  the  many  reported  cases  of  combined 
scleroses  vary  greatly.  Such  cases  must  be  of  chronic  ascending 
myelitis  or  meningomyelitis  followed  by  degeneration.  Accord- 
ing to  Marie  and  others,  the  vascular  supply  of  the  spinal  cord 
is  such  as  to  favour  sclerosis  in  the  lateral  and  posterior  columns, 
hence  chronic  leptomeningitis,  many  instances  of  which  are  due  to 
syphilitic  infection.  The  ataxic  paraplegia  described  by  Gowers, 
in  which  he  believed  the  sclerosis  lay  in  the  lateral  and  posterior 
columns  of  the  cord,  is  still  observed  as  a  clinical  entity ;  but  many 
similar  cases  can  best  be  classed  with  tabes,  with  insular  sclerosis,  or 
with  a  form  of  limited  chronic  myelitis.  We  shall  describe,  there- 
fore, only  the  hereditary  form  of  ataxia  with  paraplegia,  which  is 
congenital  and  a  family  disease  closely  related  to  Friedreich's 
ataxia ;  also  the  type  of  combined  sclerosis  in  which  ataxia,  some 
sensory  and  motor  symptoms,  are  found  associated  with  pernicious 
anaemia.  There  is  no  particular  clinical  picture  attached  to  the 
cases  of  combined  scleroses  described  by  Striimpell  and  others 
with  autopsies ;  hence  the  two  above-indicated  types  at  the  present 
stage  of  our  scientific  knowledge,  that  are  proper  subjects  for  accu- 
rate description,  clinically  and  pathologically,  are  (1)  hereditary 
ataxia  (see  Friedreich's  ataxia,  p.  238)  and  (2)  the  combined  scle- 
roses of  ance.mia,  etc., as  described  by  Lichthein.  Putnam,  and  Dana. 

(2)  COMBINED    SCLEROSIS    OF   THE   TYPE    OF 
PUTNAM-LICHTHEIN-DANA 

This  affection  occurs  past  middle  life,  and  is  usually  associated 
with  cachexia,  a  pernicious  anaemia,  or  some  toxic  states,  as  in 
influenza,  lead   poisoning,   malaria,   or  chronic   diarrhoea.      Fre- 


DISEASES    OF    THE    SPIN^AL    CORD 


261 


quently  there  is  a 
history  of  heredity. 
This  disease  was  de- 
scribed as  develop- 
ing in  the  course  of 
anaemia  byLichthein 
in  1877;  those  pro- 
duced by  other 
causes  by  Putnam, 
and  in  1891  again 
by  Dana. 

Symptoms.  — 
The  earliest  symp- 
toms are  persistent 
paresthesia,  accom- 
panied by  slight 
weakness,  most  com- 
monly in  the  feet, 
and  somewhat  later 
followed  by  ataxia. 
Pain  in  the  limbs 
and  back  may  exist. 
At  first  there  is 
some  spasticity  of 
the  muscles,  in- 
creased knee-jerks, 
and  ankle  clonus. 
Later  in  the  disease 
the  rigidity  may  dis- 
appear and  reflexes 
be  lost  in  the  lower 
extremities.  After 
some  months  the 
arms  become  affect- 
ed and  symptoms 
develop  similar  to 
those  in  the  legs. 
Occasionally  the  dis- 
ease begins  in  the 
upper      extremities. 


FxG.  63. — Combined  Sci.ekosis  of  the  Type  Put- 
nam-Lichtuein -Dana  FOLLOWED  BY  LeFT 
Hemiparesis.     (Medico-Chiiurgical  Hospital.) 


262  TREATISE    OX    XEEYOUS    DISEASES 

Lessening  or  absence  of  pain,  tactile  and  thermic  senses  may 
occur,  or  there  may  be  dissociated  sensation,  as  in  case  of  syringo- 
myelia.   In  the  course  of  the  disease  dementia  may  develop. 

Pathology. — The  posterior  columns  are  first  and  mostly  in- 
volved. In  some  cases  of  pernicious  angemia  these  were  the  only 
columns  that  were  found  to  be  sclerosed.  In  the  majority  of  cases 
the  lateral  columns  (crossed  pyramidal  tracts)  are  affected  as 
well,  and  late  in  the  course  of  the  disease  the  anterior  columns 
may  be  attacked.  Softening  of  the  cord  with  the  production  of 
cavities  may  appear.  The  condition  is  essentially  a  primary  degen- 
eration of  the  nerve-fibres. 

Diagtiosis. — This  is  to  be  distinguished  from  tabes.  It  is  rapid 
in  onset  and  there  is  some  motor  weakness,  but  absence  of  ocular 
symptoms  is  characteristic,  while  the  early  increase  of  knee-jerks 
with  the  angemia  should  be  taken  into  consideration.  From  ataxic 
paraplegia  or  posterior  lateral  sclerosis  it  is  also  told  by  its  rapid 
development,  the  greater  degree  of  weakness,  and  the  'constitu- 
tional symptoms.  Those  cases  with  dissociation  of  sensation  are 
also  distinguished  from,  syringomyelia  by  the  absence  of  severe 
pain  and  tenderness  or  of  marked  muscular  wasting. 

Prognosis. — This  is  unfavourable.  In  the  majority  of  cases 
the  patient  will  not  survive  longer  than  six  months  to  several  years, 
although  cases  of  great  improvement  have  been  reported. 

Treatment.  —  Hypernutrition.  rest,  massage,  and  Swedish 
movements.  Measures  tending  strictly  towards  eradicating  the 
diathetic  or  specific  conditions  underlying  should  be  employed. 
The  anasmia  or  any  form  of  intoxication  should  be  treated.  The 
drugs  of  value  in  the  disease  are  arsenic,  quinine,  iron,  and  other 
tonics,  together  with  nutrients. 

Ee-education  of  the  ataxic  extremities  can  be  had  where  im- 
provement may  happily  occur  if  asthenia  is  not  too  great. 

INFLAMMATIONS  OF  THE  SPINAL  CORD-MYELITIS 

Myelitis,  an  inflammatory  lesion  of  the  spinal  cord,  is  a  dis- 
ease rather  insidious  in  onset,  sometimes  very  abrupt,  and  running 
a  course  of  several  degrees;  the  first,  or  mildest,  which  fre- 
quently recovers,  leaving  little  damage  to  the  organic  constitu- 
ents of  the  cord ;  the  second,  running  a  serious  course,  and  after 
subsiding  the  individual  is   a  paraplegic ;  while  the   third  type 


DISEASES    OF    THE    SPINAL    COED  263 

is  malignant;,  rapid  destruction  of  tlie  cord  and  death  of  the  patient 
follows. 

Causes. — These  are  exposure  to  cold  and  dampness;  injury, 
such  as  a  trauma  to  the  hack;  or  it  may  be  of  a  septic  nature,  due 
to  metastasis  from  other  seats  of  infection,  including  tubercular. 

Myelitis  is  much  more  frequently  met  with  in  the  male,  on 
account  of  the  liability  to  exposure  in  men. 

Pathology. — This  condition  consists  of  a  low  grade  of  in- 
flammation with  infiltration  of  round  cells  within  the  gray  and 
white  matter,  more  particularly  of  the  gray  matter.  Granular 
debris  is  the  result,  plus  fatty  degeneration  of  the  nerve-cells,  and 
their  replacement  by  connective-tissue  elements.  Where  the  proc- 
ess has  been  insidious  and  mild  the  neurones  throughout  the 
transverse  section  of  the  cord  will  be  found  but  partially  degen- 
erated. In  malignant  cases  there  is  a  complete  destruction  of  the 
parenchyma  of  the  cord  (see  Infantile  Palsy). 

Depending  upon  the  extent  of  lesion,  we  have  iransverse,  as- 
cending, and  descending  myelitis.  The  lesion  of  poliomyelitis 
need  not  be  mentioned  here. 

Symptoms. — There  is  a  rather  sudden  onset,  a  slight  rise  in 
temperature,  parsesthesia  and  feebleness  of  the  lower  extremities. 
This  continues  more  or  less  rapidly  until  the  patient  within  a  few 
days  becomes  bedridden,  incontinence  of  urine  follows,  and  per- 
haps of  the  rectal  sphincter.  The  upper  extremities  may  be  in- 
volved, depending  upon  the  site  of  inflammation,  but  usually 
not,  since  the  process  is  generally  confined  to  the  lumbar  cord. 
In  the  beginning  the  reflexes  are  heightened,  ankle  clonus  even 
may  develop,  .and  the  patient  have  a  spastic  gait  and  become 
more  or  less  ataxic,  depending  upon  the  degree  of  involvement  of 
the  posterior  white  columns.  Usually  the  gray  matter  is  more 
involved,  and  if  the  multipolar  cells  are  affected  distinct  atrophy 
and  wasting  of  the  muscles  will  follow.  In  a  rapidly  progressive 
myelitis,  parsesthesia  and  hypergesthesia  (irritative  symptoms) 
will  within  a  few  days  to  a  week  be  replaced  by  a  hypEesthesia  or 
anaesthesia,  involving  both  lower  extremities  very  likely  in  their 
extent,  or  the  trunk  may  be  thus  affected  as  high  up  as  the  umbili- 
cus. At  this  stage  bladder  distress  from  incontinence  and  paresis 
of  the  detrusor  muscle  will  permit  of  retention  of  urine  as  well, 
and  resulting  cystitis.  At  this  time,  too,  bedsores  may  occur,  par- 
ticularly liable  over  the  buttocks  and  sacral  region,  due  to  the  low- 


264  TKEATISE    ON    NEEVOUS    DISEASES 

ered  trophic  condition  and  pressure  upon  these  dependent  parts. 
At  this  last  stage  the  reflexes  will  be  abolished.  The  patient  is  rest- 
less, loses  flesh,  and  becomes  hectic,  and  may  go  into  a  septicsemia, 
which  may  cause  death ;  or  after  a  number  of  weeks  the  inflamma- 
tion may  subside  and  the  paresis  partly  recover,  permitting  the 
patient  to  get  about  on  crutches  within  a  few  months  to  a  year. 
In  other  cases  the  destruction  of  the  cord  may  be  so  absolute 
that  even  partial  recovery  of  function  seldom  occurs,  although 
held  in  abeyance,  and  the  patient  may  go  on  living  a  vegetative 
life  for  some  months  or  years.  This  is  especially  apt  to  result 
in  those  cases  of  traumatic  origin,  such  as  in  "  broken  back  "  of 
the  coal  miner. 

In  some  few  cases  I  have  seen  almost  entire  recovery  after  a 
most  severe  attack,  and  in  these  cases  it  is  very  likely  that  the 
meninges  have  been  particularly  involved,  and  while  the  function 
of  the  cord  for  the  time  is  greatly  interfered  with,  the  absolute 
destruction  of  the  neurones  has  not  occurred.  The  extremities  in- 
volved in  m3^elitis  become  cold,  clammy,  cyanosed,  etc.  On  begin- 
ning recovery  of  a  case  the  patient  moves  about  with  a  spastic 
gait,  which  he  will  retain  in  some  measure,  although  he  may  pretty 
completely  recover  from  the  palsy. 

Diagnosis. — This  is  to  be  made  from  neuritis,  Avhere  pain  and 
tenderness  along  nerve-trunks  would  differentiate ;  from  subacute 
rheumatism  of  the  limbs,  which  would  be  distinguished  by  the 
nature  and  distribution  (to  the  joints)  of  the  pain  with  other  symp- 
toms of  the  rheumatic  disorder ;  and  finally  from  syphilis  of  the 
spinal  cord,  where  the  course  of  the  disease  is  much  slower,  and 
spasticit}^  is  out  of  proportion  to  palsy.  In  syphilis  too  seldom  are 
the  signs  equally  bilateral ;  paresis  is  less  marked  and  muscle  tone 
not  increasing  in  proportion  to  the  heightened  reflexes  existing,  as 
indicated. 

Prognosis. — This  is  a  very  difficult  matter  to  determine.  It 
should  be  held  in  abeyance  until  the  first  few  weeks  of  the  dis- 
ease have  passed,  and  will  depend  in  some  measure  upon  the  phys- 
ical stamina  of  the  patient,  although  distinctly  plethoric  persons 
are  apt  to  suffer  the  greatest.  Infectious  cases  particularly  will 
often  recover  more  completely  than  the  so-called  idiopathic  class. 
The  tubercular  cases  are  the  most  promising  for  restoration  of 
the  function  of  the  cord.  Here,  again,  the  inflammation  is  liable 
to  be  localized  in  the  membranes. 


DISEASES    OF    THE    SPINAL    COED  265 

Treatment. — This  consists  in  absolute  "rest  in  bed,  preferably  a 
water-bed;  the  use  of  mild  antipyretics,  if  the  case  is  fulminating 
in  type,  and  there  is  much  constitutional  involvement.  Protection 
should  be  had  to  the  extremities  by  means  of  "  hoops  "  to  sustain 
the  bed-clothing,  and  the  dependent  part  should  be  amply  guarded 
against  prolonged  pressure  by  frequent  changes  of  the  position  of 
the  patient.  The  use  of  analgesics  may  be  necessary  ( phenacetine, 
5  grains)  where  there  is  considerable  distress.  The  bladder  should 
be  guarded,  especially  for  retention  of  urine,  by  a  careful  use  of 
the  catheter,  both  to  prevent  injury  of  the  mucous  membrane  and 
from  the  aseptic  point  of  view.  If  marked  cystitis  develops  it  may 
be  necessary  to  flush  the  bladder  with  some  antiseptic  solution,  as 
boracic  acid  or  a  minimum  solution  of  potassium  permanganate 
(1  grain  to  a  quart  of  water).  The  decubitus  developing  should 
be  antiseptically  cleansed,  and  a  soap  plaster  placed  around  the 
adjacent  tissues  to  prevent  pressure  on  the  sore,  the  latter  being 
antiseptically  treated.  The  so-called  "  ring,"  when  used,  I  have  not 
seen  of  practical  value,  since  it  disturbs  the  patient,  and  will  slip 
and  only  do  more  damage  in  the  already  inflamed  area.  Among 
drugs,  the  solution  of  potassium  iodide,  directed  to  be  taken  in 
5-  to  lO-grain  doses,  t.  i.  d.,  is  of  great  value  from  its  sorbefacient 
effect  upon  the  exudate  about  and  in  the  cord  substance.  This 
should  not  be  pushed  to  a  high  dosage,  as  in  cases  of  specific  dis- 
ease, which  shall  be  mentioned  in  the  next  chapter.  Prolonged 
rest  is  essential  for  the  hastening  of  good  results.  The  necessity 
for  care  of  the  skin  in  any  case  is  to  be  insisted  upon  by  the  proper 
bathing  and  stimulation  with  alcohol,  etc.  Thorough  massage  is  a 
valuable  aid  in  restoration  of  tone  of  the  muscles  in  convalescing 
cases,  and  should  be  continued  for  months.  When  the  patient  gets 
about  he  should  be  cautioned  to  use  crutches  or  a  cane  and  to 
avoid  activit}^,  lest  he  increase  the  inflammatory  process. 

The  treatment  for  myelitis  following  Pott's  disease  differs  in 
one  particular — i.  e.,  in  the  use  of  extension  and  counter-extension 
to  the  patient  by  means  of  the  jury-mast,  which  is  weighted  from 
the  head  of  the  bed,  the  counter-extension  being  made  by  elevation 
of  the  head  of  the  bed.  This  extension  may  be  increased  to  from 
10  to  30  pounds,  and  should  be  practically  continuously  applied  to 
the  patient  until  the  inflammation  of  the  vertebrge  subsides  and 
the  palsy  has  partially  recovered.  This  class  of  cases  comes  under 
the  neurologist's  care  when  the  paraplegia  is  marked,  and  may 


206  TKEATISE    OX    XERVOrS    DISEASES 

reach  the  orthopaedist  when  the  vertebral  sjrmptoms  predominate. 
Another  method  of  extension  is  by  suspension  of  the  patient  while 
sitting  in  a  chair  by  means  of  an  inverted  "  L  "-shaped  rod  at- 
tached to  the  back  of  the  chair,  to  the  short  end  of  which  a  pulley, 
scales,  and  the  head-extension  apparatus  is  attached.  This  can  be 
nicely  adjusted  to  the  weight  desired  for  the  extension.  I  have 
seen  patients  with  complete  motor  and  sensory  palsy  of  three 
months'  duration  recover  entirely  from  palsy,  by  combination  of 
the  bed-and-chair  extension  described,  within  seven  months  of  per- 
sistent treatment.  The  tendency  in  these  cases  to  relapse  is  to 
be  noted,  and  a  brace  should  always  be  worn  afterward  to  support 
the  spinal  column.  Cases  of  Pott's  disease  with  suppuration  are 
least  apt  to  develop  paralysis,  very  likely  because  extension  is  out- 
ward rather  than  inward  in  pus  cases;  also  due  to  the  apparent 
immunity  of  nervous  tissue  to  sepsis. 


CHAPTER    XY 
DIFFUSE  DISEASES  OF  BRAIN  AND   CORD 

Multiple  sclerosis,  or  insular  sclerosis,  or  disseminated  sclerosis, 
or  sclerose  en  plaques,  is  a  chronic  affection  characterized  by  focal 
areas  of  sclerosis  scattered  throughout  the  brain  and  cord;  occa- 
sionally the  sclerosis  is  limited  to  the  brain  or  to  the  cord. 

^Etiology. — Multiple  sclerosis  may  be  the  result  of  trauma,  as 
of  the  spine,  to  the  influence  of  exposure  to  cold  and  wet  when 
various  metabolites  and  toxins  are  developed  in  the  blood  as 
sources  of  irritation.  Overwork  may  in  the  same  way  act  as  an 
exciting  cause,  as  will  emotional  states,  which  may  also  much  per- 
vert all  bodily  secretions  and  excretions.  Infectious  diseases  or 
the  metallic  poisons,  such  as  of  lead  or  mercury,  may  also  act  as 
causes. 

Symptoms. — The  symptoms  will  vary  in  accordance  with  the 
distribution  of  the  sclerosis  as  well  as  its  extent.  Still  there  are 
certain  signs  and  symptoms  of  sufficient  importance  to  be  char- 
acteristic. These  consist  of  weakness  of  one  or  more  extremities, 
such  as  of  the  legs.  The  limbs  become  spastic,  the  deep  reflexes 
being  increased.  A  coarse  tremor  develops  in  the  affected  parts, 
and  this  is  of  the  intention  type — i.  e.,  it  is  awakened  or  exagger- 
ated by  volition  or  a  voluntary  act.  These  irregular  tremors  may 
involve  the  arms,  legs,  and  finally  the  head.  The  tremor  usually 
subsides  when  the  parts  are  at  rest,  and  absolutely  so  when  the 
patient  sleeps.  Occasionally  the  tremor  is  so  coarse  that  it  is  diffi- 
cult to  differentiate  it  from  ataxic  movements.  Nystagmus  is  a 
common  symptom.  This  may  be  persistent,  and  is  usually  lateral 
nystagmus.  It  may,  however,  only  be  brought  out  by  having  the 
patient  strain  the  eye  muscles,  as  in  looking  far  to  one  side  in 
attempting  to  produce  conjugate  deviation.  Ophthalmoplegia 
may  finally  occur.  Optic  atrophy  is  frequently  found,  but  the 
Argyll-Eobertson  pupil  seldom  occurs.  The  lower  cranial  nerves, 
such  as  the  fifth,  seventh,  and  twelfth,  may  be  also  involved. 
Speech  is  apt  to  be  affected;  when  it  is  slow  and  sing-song  with 

267 


268  TEEATISE    OX    XEEA'OUS    DISEASES 

elision  of  letters  and  words.  The  patient  articulates  as  in  scanning 
poetry,  the  so-called  staccato  utterance  or  scanning  speech.  Some- 
times atypical  forms  of  dysarthria,  resembling  the  speech  in  bulbar 
palsy,  or  Friedreich's  ataxia,  or  even  paretic  dementia,  may  be 
seen.  At  times  patients  affected  with  insular  sclerosis  may  be  sub- 
ject to  attacks  of  vertigo,  apoplectiform  or  epileptiform  seizures. 
In  unusual  cases  anEesthesia  may  be  existent,  when  it  occurs  in 
the  form  of  small  irregular  patches,  although  if  a  sensory  tract  is 
involved  and  destroyed  high  up  hemianesthesia  may  result.  Of 
course  various  forms  of  pargesthesia  may  be  found,  since  irritation 
of  sensory  tracts  without  destruction  of  them  is  the  more  fre- 
quent condition  present  in  the  brain  or  cord  in  this  disease. 

Diagnosis. — Most  of  the  cardinal  symptoms  just  enumerated 
will  at  once  serve  to  differentiate  this  malady  from  any  form  of 
system  disease,  which  latter  would  only  be  simulated  where  there 
is  a  large  plaque  involving  a  special  tract,  as  the  sensory,  for  ex- 
ample, as  mentioned  above.  The  symptoms  may  remain  entirely 
cerebral  or  spinal.    Eemissions  are  frequent. 

Intention  tremor,  scanning  speech,  and  nystagmus  are  rare  in 
cerehro-spinal  syphilis;  while  in  syphilis,  too,  there  may  be  irido- 
plegia  in  one  or  both  eyes,  or  the  pupils  may  be  irregular  in  con- 
tour from  previous  synechise,  which  latter  would  never  occur  in 
insular  sclerosis  (Sachs).  The  tremor  of  paralysis  agitans  is  more 
marked  when  the  part  is  at  rest,  and  it  is  inhibited  by  volition  or 
voluntary  movements — a  dynamic  or  continuous  tremor.  Parkin- 
son's disease  is  also  one  of  old  age,  and  true  scanning  speech  or 
nystagmus  are  neither  present  in  it.  Paraplegic  forms  of  infantile 
cerehral  palsies  are  told  by  their  appearance  in  very  early  life, 
occurrence  of  convulsions,  associated  with  a  more  pronounced  fail- 
ure of  mental  development.  The  diplegic  type  is  more  difficult  to 
distinguish,  since  scanning  speech,  nystagmus,  and  ataxic  move- 
ments may  be  present.  The  syndrome  of  all  three  of  these  last- 
mentioned  symptoms  is,  however,  seldom  found  in  cerebral  palsy; 
also  paralysis  and  contractures  are  apt  to  be  marked  in  cerebral 
palsy.  In  the  hereditary  ataxia  of  Friedreich,  optic  atrophy,  less- 
ened or  absent  reflexes  and  ataxia  of  lower  limbs  are  points  in 
diagnosis.  From  the  cerelellar  type  of  hereditary  ataxia  it  is  more 
difficult  to  distinguish.  Eomberg's  sign,  which  is  present  in  cere- 
bellar ataxia,  is,  however,  very  rare  in  multiple  sclerosis. 

Prognosis. — Insular  sclerosis  is  slow  in  progress,  but  is  incur- 


DIFFUSE    DISEASES    OF    BRAIX    AND    CORD     269 


able.    Remissions  ma}^  occur  spontaneous!}^  or  may  be  clue  to  treat- 
ment in  those  patients  with  good  physiques. 

Treatment. — Alterative  remedies,  such  as  arsenic  or  Donovan's 
solution,  or  even  the  iodides,  may  be  of  much  service.     oSTitrate 
of  silver  has  been  commended,  but  I  have  never  seen  benefit  from 
its    use.      Re-education    by 
teaching  the  patient  to  co- 
ordinate is  of  value  in  the 
symptomatic      management 
of  the  case.    Massage  is  im- 
portant.    General  nutrition 
of    the    patient     (such    as 
through     the      administra- 
tion of  syr.  ferri  iodidi,  gtt. 
XV,  t.  i.  d.,   or   cod-liver   oil 
§ss.  after  meals)  is  the  most 
important  part  of  treatment. 

PARALYSIS    AGITANS 
(SHAKING    PALSY) 

Paralysis  agitans  is  a 
disease  occurring  more  fre- 
quently about  the  fifth  dec- 
ade of  life,  and  in  which 
tremor  and  palsy  are  fea- 
tures. The  name  ParJan- 
S07i^s  disease  is  also  applied. 

Causes'.  —  Heredity, 
overwork,  or  trauma  to 
spine. 

Symptoms. — The  cardi- 
nal features  are  paresis,  ac- 
companied by  fine  constant 
tremor,  beginning  as  a  rule 
in  the  hands,  face,  and 
lips,  gradually  spreading  until  the  entire  musculature  is  involved. 
The  tremor  is  a  continuous  one  in  the  majority  of  cases  when  the 
disease  has  become  well  established,  although  there  is  the  unusually 
rare  case  that  does  not  manifest  tremor  except  periodically.     The 


Pig.  63.  —  Expkession,  "Pill-rolling'" 
Hands,  and  Attitude  in  Pakalysis  Agi- 
tans (Adult  Male  ;  but  little  Tkem- 
Ok).     (Philadelphia  Hospital.) 


270  TREATISE    ON    NERVOUS    DISEASES 

tremor  is  never  what  we  designate  an  intention  tremor — i.  e.,  one 
brought  out  by  voluntary  movement  of  the  parts;  in  this  we  have 
a  diagnostic  symptom,  as  between  it  and  insular  sclerosis,  in  which 
there  is  generally  marked  intention  tremor.  Other  signs  of  paral- 
ysis agitans  are  a  masked  expression,  the  so-called  "  wooden  face," 
due  to  rigidity  and  immobility  of  the  muscles  of  expression ;  and 
increased  reflexes.  With  these  there  is  slowness  of  cerebration, 
and  still  more  of  articulation  due  to  mechanical  interference  with 
speech  from  lingual  and  pharjmgeal  involvement  in  the  muscular 
rigidity  and  paresis.  Later,  as  the  disease  slowly  advances,  drib- 
bling of  saliva,  very  marked  stooping  of  the  body  with  rigidity  of 
the  neck,  an  assumption  of  the  pill-rolling  position  of  the  hands 
and  fingers  are  characteristic,  and  finally. the  festinating  gait,  or 
running  gait  as  it  is  sometimes  called.  This  gait  is  really  an  exag- 
geration of  that  of  old  age,  and  in  which  the  patient  is  said  to 
be  running  after  his  centre  of  gravity  (not  an  inapt  term).  If 
the  subject  feels  himself  falling  forward,  the  term  propulsion  is 
implied;  if  he  has  the  sense  of  falling  backward,  we  designate  it 
retro  pulsion.  The  circulation  is  generally  feeble  in  these  patients, 
cardiac  palpitation  is  not  uncommon  upon  slight  exertion,  there 
is  usually  marked  arteriosclerosis,  and  frequently  iridoplegia  in 
myosis.  The  tremor  in  its  incipiency  is  also  more  marked  when 
the  patient  is  relaxed,  though  it  is  exaggerated  with  the  relaxation 
following  extraordinary  exertion  for  him;  and  finally  tremor  may 
become  so  large  and  persistent  that  sleep  is  prevented  from  the 
mere  mechanical  effects  upon  the  body,  but  when  the  patient  does 
sleep  the  tremor  disappears  for  the  time  being.  Save  for  pares- 
thesia no  sensory  symptoms  are  found,  excepting  in  rare  cases, 
where  there  are  rheumatic  or  articular  changes  of  a  trophic  nature 
in  the  joints,  when  fleeting  arthritic  pains  may  occur.  The  patient 
is  eventually  compelled  to  give  up  the  use  of  the  hands,  as  in 
writing  first,  then  of  larger  movements;  although  it  is  singular, 
the  ability  to  write  is  preserved  to  extreme  advance  of  the  disease 
in  some  cases.  Local  flushing  of  the  face  and  neck  and  body 
with  evanescent  sweating  of  the  parts  is  always  a  notable  symp- 
tom in  this  disease,  due  to  vaso-motor  irritability.  The  sphincter 
muscles  are  almost  never  incontinent. 

The  duration  of  paralysis  agitans  is  indefinite.  As  the  disease 
is  incurable  in  itself  and  occurs  at  the  degenerative  period  of  life, 
the  demise  of  the  patient  will  depend  upon  the  complication  of 


DIFFUSE    DISEASES    OF    BRAIN"    AND    CORD     271 

other  maladies,  or  upon  the  degree  of  degenerative  tendency  in 
the  individual.  The  latter  should  he  sought  for  in  some  measure 
by  noting  the  heredity  of  the  family. 

Pathology. — While  no  lesion  has  been  found  in  the  majority 
of  cases  coming  to  necropsy,  in  a  fair  proportion  of  them  changes 
in  the  cord  have  been  noted,  largely  consisting  of  congestion  and 
dilatation  of  blood-vessels  of  the  gray  matter,  atrophy  and  pig- 
mentation of  nerve  cells,  and  increase  of  the  interstitial  tissue. 
Dana  considers,  however,  that  the  central  motor  neurone  is  most 
at  fault. 

Prognosis. — As  inferred  from  the  above,  recovery  never  occurs ; 
but  taken  early,  the  malady  can  be  controlled  very  materially  in 
25  per  cent  of  the  cases.  Remissions  and  exacerbations  are  nota- 
ble. I  have  in  mind  a  patient,  who  will  be  referred  to  under  treat- 
ment, in  whom  there  has  been  very  marked  amelioration  of  the 
sym.ptoms,  especially  in  the  restoration  of  general  tone  to  the  sys- 
tem, although  the  tremor  has  never  been  greatly  improved.  An- 
other advanced  case  at  the  Philadelphia  Hospital  under  my  care 
has  been  greatly  improved  as  to  the  tremor  itself  by  therapeutic 
measures.  Where  it  is  clearly  shown  that  there  is  no  family  tend- 
ency to  the  disease  we  can  hope  for  better  results  than  in  cases 
with  neurotic  taint  in  a  preceding  generation.  Just  when  the 
stage  of  paresis  will  develop  cannot  be  accurately  foretold,  although 
generally  speaking,  the  greater  extent  and  range-  of  tremor  the 
earlier  will  palsy  result. 

Treatment. — The  essentials  in  treating  paralysis  agitans  are 
rest  and  hypernutrition.  In  an  incipient  case,  therefore,  ideal 
treatment  lies  in  change  of  scene,  the  leading  of  a  quiet  life,  with 
abundance  of  fresh  air  and  sunlight.  Light  gymnastics  and  pas- 
sive movements  are  of  value  in  preventing  rigidity  of  the  limbs. 

Tonics,  as  quinine,  arsenic,  and  mineral  acids,  are  helpful. 
Warm  baths  daily  and  the  constant  galvanic  current  are  of  value. 
Hyoscine  hydrobromate,  gr.  ^^-^  t.  i.  d.,  will  frequently  relieve  the 
symptom  tremor,  or  a  com.bination  of  tincture  of  conium  and  tinc- 
ture of  hyoscyamus,  equal  parts,  given  in  5-  to  10- drop  doses,  is 
of  service.  Gowers  recommends  cannabis  indica  and  arsenic.  I 
have  seen  the  Brown-Sequard  ^  injections  do  good.  Elimination 
through  skin,  kidneys,  and  intestinal  tract  must  be  regulated. 

*  Testicles  of  healthy  bulls  are  ligated  and  excised  immediately  after  kill- 
ing the   animal.      Under  antiseptic  precantions  the  tunics  are  completely 


272  TREATISE    0^    NERVOUS    DISEASES 

SYPHILIS    OF    THE    NERVOUS    SYSTEM 

General  Considerations  and  Distmctio'ns 

Scientifically  speaking,  "  syphilis  of  the  nervous  system " 
applies  to  the  tertiary  lesion  located  in  the  membranes  of  the  brain 
or  cord,  or  both;  although  parasyphilitic  disease  or  the  toxin  stage 
(or  quarternary  stage  of  some  authors)  is  also  a  sequela  of  syph- 
ilis. In  the  latter,  however  (as  in  tabes  and  paresis),  there  are  no 
characteristic  lesions  of  syphilis.  In  it,  too,  the  specific  poison 
may  expend  itself  upon  the  progeny,  affect  the  general  health, 
lessening  resistance,  and  may  create  morbid  tendencies  or  even 
sclerosis,  as  inferred  above,  in  descendants  of  parasyphilitics. 

The  acquired  syphilitic  diseases  of  this  parasyphilitic  stage 
may  therefore  be  paresis,  ataxia,  neurasthenia,  hysteria,  epilepsy, 
and  mental  diseases.  The  congenital  syphilitic  diseases  of  this 
same  stage  may  be  arrest  of  development  (as  in  Little's  disease), 
hydrocephalus,  paresis,  juvenile  tabes,  the  hereditary  form  of  cere- 
bral palsies  in  children,  etc.  We  have  described  all  these  various 
parasyphilitic  diseases  in  other  chapters. 

NERVOUS    SYPHILIS 

General  Considerations. — In  the  so-styled  specific  form  of  S3'ph- 
ilitic  disease  of  the  central  nervous  system  there  may  be  the  hered- 
itary or  acquired  forms.  In  the  former,  symptoms  are  present 
at  birth  or  may  appear  early  in  childhood.  Very  rarely  this 
form  may  even  appear  late  in  life,  affecting  all  parts  of  the  nervous 
system  singly  or  collectively.  The  acqmred  and  usual  form  may 
appear  at  various  times  after  the  primary  lesion.  Usually  symp- 
toms present  between  eighteen  months  and  six  3^ears.  Some  acute 
fulminating  cases  may  even  occur  during  the  secondary  period. 
Others  may,  exceptionally,  occur  even  after  thirty  years  of  the 
luetic  infection. 

Pathology. — There  are  various  forms  of  tertiary  lesion  found. 

(1)  Disease  of  Blood-Vessels. — Endarteritis  ohliterans  is  fre- 
quently found  in  which  there  is  proliferation  of  endothelial  and 

removed  down  to  and  including  the  albuginea.  The  gland  is  then  macerated 
in  pure  glycerin  and  allowed  to  dissolve  for  forty-eight  hours.  The  whole  is 
then  filtered  and  a  small  extra  amount  of  the  liquid  part  of  the  residue  is 
added  to  make  a  supersaturated  solution.  The  mixture  is  then  sealed  in  anti- 
septic phials.     By  this  method  one  testicle  is  equal  to  one  ounce  of  solution. 


DIFFUSE    DISEASES    OF   BRAIN    AND    COED     273 

subendothelial  cells.  This  much  thickens  the  walls  of  the  blood- 
vessels, and  narrows  and  sometimes  obliterates  them  completely. 
The  other  coats  may  also  be  destroyed.  Periarteritis  in  which 
nodular  gummata  may  develop  in  the  adventitia  of  the  vessels  may 
produce  globular  or  ovoid  swellings.  The  interna  may  or  may  not 
become  diseased.  Secondary  thrombosis,  softening,  or  rupture  or 
the  development  of  aneurysms  may  occur  from  any  of  these  blood- 
vessel lesions.  Cases  where  the  secondary  symptoms  have ,  been 
mild  are  particularly  apt  to  develop  syphilis  of  the  nervous  system. 
This  is  probably  due  to  insufficiently  treated  specific  disease  or  to 
a  vulnerable  nervous  system,  or  both. 

(2)  Gummata. — These  may  be  single  or  multiple,  and  usually 
involve  the  pia  mater,  affecting  the  brain  or  cord  secondarily,  fre- 
quently only  by  compression.  They  spring  from  the  walls  of  the 
blood-vessels,  and  are  composed  of  round  cells  derived  from  them 
and  from  proliferated  connective-tissue  cells.  Hence  the  walls  of 
the  blood-vessels  becom.e  thickened.  A  gummatous  meningitis  also 
is  usually  found.  The  gummata  may  be  attached  to  the  dura,  and 
rarely  to  a  vessel  of  the  brain  or  cord  substance  proper.  Gummata 
are  not  as  commonly  found  in  the  cord  as  in  the  brain.  In  the 
brain  they  are  usually  seen  upon  the  cortex  or  in  the  pons  (hence 
the  symptoms  of  palsy  will  depend  on  location  of  growths). 

(S)  Gummatous  Meningitis. — This  is  a  condition  in  which  the 
membranes  are  infiltrated  with  cells,  and  are  much  thickened  in 
consequence.  This  is  found  always  about  gummatous  masses,  but 
may  exist  separately.  It  is  more  common  at  the  base  of  the  brain, 
and  generally  involves  the  dura.  Gummatous  growth  themselves 
are  much  less  frequent  at  the  base  than  is  specific  meningitis. 

Symptoms  of  Cerebral  Syphilis. — The  onset  of  symptoms  is 
generally  from  three  to  six  years  after  the  initial  specific  lesion  or 
chancre.  The  patient  will  complain  of  drowsiness  in  the  daytime 
and  wakefulness  at  night,  with  persistent  headache,  due  to  menin- 
geal irritation  and  inflammation.  According  to  H.  C.  Wood,  he 
becomes  a  restless  nocturnal  automaton.  The  mental  conditions 
of  obtundity,  with  failure  of  memor}^,  but  without  delusions,  are 
other  distinctly  psychic  phenomena.  Ocular  palsies  are  very  likely 
to  develop  early,  perhaps  the  first  svmptom  being  that  the  patient 
will  complain  of  seeing  double  (diplopia)  ;  or  it  may  be  noted  that 
he  has  a  strabismus,  or  on  testing  the  ocular  balance  that  the  move- 
ments are  restricted,  due  to  neuritis  of  the  ocular  motor  nerves, 
18 


274  TEEATISE    ON    KEEVOUS    DISEASES 

because  basilar  exudate  is  common.  The  patient  is  physically 
weak;,  the  reflexes  are  heightened,  due  to  the  chronic  irritation  of 
the  motor  tracts  and  centres;  and  localized  palsies  may  supervene 
in  other  places,  such  as  in  an  arm  or  a  lower  extremity,  due  to 
destruction  or  pressure  upon  the  motor  centres.  Acute  optic  neu- 
ritis and  optic  atrophy  may  develop,  but  is  uncommon,  while 
"  choked  disk  "  is  but  seldom  seen,  thus  differing  from  eye  symp- 
toms of  brain  tumour.  The  patient  may  develop  convulsions  from 
time  to  time  in  proportion  as  the  process  is  chronic.  Various 
parsesthesige  of  the  extremities  may  occur  in  cerebral  syphilis.  A 
palsy  is  almost  never  complete  in  this  disease,  and  the  vacillation 
from  month  to  month  is  a  point  in  favour  of  this  diagnosis.  One 
of  the  principal  points  in  the  symptomatology  of  cerebral  syphilis, 
we  wish  to  insist,  is  early  palsy  of  the  ocular  or  other  cranial 
nerves.  Such  palsy  also  varies  much  in  extent  from  week  to  week, 
according  as  active  specific  treatment  is  pursued  or  not. 

Symptoms  of  Spinal  Syphilis. — ^^\^hile  the  symptoms  are  usu- 
ally conjoined  with  those  of  cerebral  syphilis,  still  the  predomi- 
nance of  the  spinal  disease  occurs  in  a  sufficient  number  of  cases  to 
warrant  the  title  given,  and  which  has  frequently  been  called,  since 
Erb  first  well  described  it,  Eri's  paralysis.  The  time  of  onset  of 
spinal  syphilis  is  the  same  as  that  of  cerebral  syphilis  (usually  two 
to  four  years  after  infection).  An  early  complaint  is  of  pargesthesia 
of  the  lower  extremities,  accompanied  by  feebleness  and  a  sense 
of  rigidity  of  the  muscles,  with  at  the  same  time  incontinence 
of  urine  or  difficiilty  of  urination,  clue  to  weakness  of  the  vesical 
sphincter.  Indeed  bladder  sym.ptoms  are  the  earliest  symptoms  of 
the  disease.  The  reflexes  are  heightened,  the  knee-jerks  being 
greatly  increased,  and  marked  sustained  ankle  clonus  occurs.  Sel- 
dom is  there  ansesthesia,  but'  hypersesthesia  or  hypgesthesia  fre- 
quently exists  of  irregular  distribution,  depending  upon  the  seg- 
ment of  the  cord  and  roots  involved.  Some  disturbance  of  co-ordi- 
nation and  Eomberg's  symptom  may  be  present.  A  clinical  point 
of  partfcular  note  is  the  heightened  reflexes  out  of  proportion  to 
palsy  and  the  associated  proportionate  diminution  of  muscular 
tone;  so  that  seldom  do  contractures  occur,  even  though  the  knee- 
jerk  is  wildly  spastic.  The  muscle  development  remains  good; 
there  is  seldom  wasting  or  fibrillary  contractions,  but  cyanosis  and 
coldness  of  extremities  among  vaso-motor  phenomena  are  fre- 
quently seen.     Bedsores  or  other  severe  trophic  changes  are  rare. 


DIFFUSE    DISEASES    OF    BRAIN    AND    CORD     375 

because  all  nerve-paths  are  seldom  entirely  destroyed.  The  non- 
symmetrical distribution  of  symptoms  is  also  a  special  clinical  fea- 
ture in  syphilis  of  the  spinal  cord,  as  is  also  the  remission  of  the 
symptoms. 

The  duration  is  indefinite,  and  tends  towards  degeneration 
or  sclerosis  if  not  properly  treated.  The  patient  is  liable  to  sud- 
den death,  though  usually  the  course  is  slow. 

Diagnosis. — Careful  observation  should  not  confound  this  dis- 
ease with  any  other  malady.  Confusion  may  be  had  with  myelitis, 
where  the  symptoms  are  symmetrical  in  distribution,  seldom  with 
remission,  while  the  onset  is  acute  in  character  and  accompanied 
by  bed-sores.  There  are  also  distinct  sensory  symptoms,  such  as 
girdle  sense  and  ansesthesiae,  throughout  the  course  of  myelitis. 

Prognosis  of  Cerehro-Spinal  Syphilis. — It  is  most  hopeful  of 
all  organic  affections  of  the  central  nervous  system,  excepting  in 
the  fulminating  cases,  where  the  profound  intoxication  destroys 
the  nerve-cells  before  relief  can  be  had  through  timely  treatment. 
These  latter  cases  are  the  rarest  and  do  not  present  the  typical 
features  described  above. 

Treatment. — This  consists  in  vigorous  and  thorough  appli- 
cation of  antisyphilitic  remedies.  The  use  of  potassium  iodide, 
increased  to  100  or  200  grains  a  day  (taken  in  solution),  will 
prove  of  greatest  value.  It  is  astonishing  to  see  the  good  results 
obtained  in  the  cases  that  have  received  prompt  and  early  treat- 
ment. Where  the  iodide  cannot  ,be  borne,  or  in  case  there  be  no 
response  to  the  drug,  the  use  of  bichloride  of  mercury  in  ^^- 
grain  doses,  rapidly  increased,  is  a  therapeutic  procedure  of  great 
value.  Inunctions  of  mercurial  ointment  into  the  axilla  and 
groins,  on  alternate  days,  will  also  be  efficacious.  During  the 
administration  of  antisyphilitic  measures  the  efficacy  of  the  drug 
action  may  be  bettered  by  the  use  of  hot  steam  (Russian)  baths 
given  once  or  twice  weekly.  The  stomach  must  be  conserved  in 
all  cases,  and  if  gastric  symptoms  occur  the  syphilitic  treatment 
should  be  held  in  abeyance  for  a  time  and  gastric  sedatives  and 
tonics  administered,  after  which  the  specific  treatment  may  again 
be  resorted  to.  Reconstructives  are  essential,  such  as  cod-liver 
oil,  phosphorus,  and  hvpophosphites.  Copious  draughts  of  water 
should  be  given,  and  the  bowels  should  be  kept  freely  open  and  the 
contents  soluble  by  means  of  salines.  The  diet  should  be  of  a  sim- 
ple, wholesome  nature,  such  as  eggs,  milk,  and  other  proteid  food 


276  TliEATISE    0^   XERVOUS    DISEASES 

in  limited  measure.  Careful  treatment  of  syphilis  of  the  nervous 
system,  as  outlined  above,  persisted  in  for  six  months'  time  at  least, 
will  often  produce  excellent  results ;  and  some  cases  seem  to  be  re- 
stored to  normal  health.  If  improvement  does  not  occur  within 
six  months  degeneration  of  the  nerve-cells  has  most  likely  set  in, 
and  a  favourable  issue  cannot  then  be  expected,  although  treat- 
ment should  be  continued  with  the  idea  of  ameliorating  the  dire 
effects  of  the  syphilitic  poison  or  toxin  itself. 


CHAPTER    XVI 


,  GENERAL  AND  FUNCTIONAL  NERVOUS  DISEASES 

In  functional  nervous  diseases  no  definite  known  anatomical 
change  underlies  the  morbid  alteration  of  function.  We  there- 
fore classify  such  affections  clinically.  There  may  be  made,  how- 
ever, pathogenic  and  etiological  classifications.  Thus  we  may  have 
primary  or  degenerative  and  secondary  or  acquired  neuroses. 
This  classification  is  helpful,  though  not  perfectly  correct,  because 
several  factors  often  enter  into  the  cause  of  the  same  disease. 
Classification  should  not  be  made  a  fetich. 

Dana  gives  the  following  classification,  which  serves  well  in 
the  majority  of  diseases  of  this  nature : 


Primary  degenerative  neuroses . . .  ^ 


Exhaustion  and  shock  neuroses. 


Primary  neurasthenia,  hypochondriasis. 
Epilepsy. 
Hysteria  major. 
Hereditary  chorea. 
I  General  spasmodic  tics. 
L  Myotonia. 
''Neurasthenia. 
Hysteria. 

Exophthalmic  goitre. 
Occupation  neuroses. 

f  Tic  douloureux. 
'Acquired  degenerative  neuroses.  ■{  Local  spasmodic  tics. 

1^  Paralysis  agitans. 

'  Chorea, 
Tetanus. 
Tetany. 
Rabies. 

Tremor  and  neuralgia. 
Vaso-m'otor,    trophic, 
and  sleep  disorders. 
(See  appendix.) 

We  shall  give  the  most  important  of  the  general  and  functional 
diseases  of  the  nervous  system,  classifying  them   clinically,  but 

977 


Acquired  neuroses.  « 


From     infectious,     autochtho- 
nous, and  mineral  poisons. 


Miscellaneous. 


278  TREATISE    ON    NERVOUS    DISEASES 

with  the  understanding  that  the  cause  of  the  disease  is  always  borne 
in  mind  to  be  of  first  importance  in  considering  its  treatment. 

CHOREA   MINOR,  SYDENHAM'S    CHOREA   OR 
ST.  VITUS'S    DANCE 

Chorea  is  a  general  disease,  at  present  designated  functional, 
since  its  aetiology  is  not  definitely  decided.  An  autochthonous  poi- 
son, as  in  rheumatism  or  other  diathetic  disease,  may  be  the  excit- 
ing cause ;  or  it  may  possibly  be  infectious  in  origin.  Usual  excit- 
ing causes  are  mental,  moral,  or  physical  trauma  (fright,  blow 
upon  the  head,  etc.).  Anaemia  and  general  ill  health  and  heredity 
are  predisposing  factors. 

Definition. — Chorea  is  a  functional  nervous  disease  associated 
with  irregular  inco-ordinate  movements  of  the  voluntary  muscles, 
and  accompanied  by  mental  obtundity,  anaemia,  and  at  times  car- 
diac and  rheumatic  symptoms. 

Paralytic  chorea  is  the  name  applied  to  that  form  of  St.  Yitus's 
dance  where  muscle  palsy  from  exhaustion  is  markedly  present. 
There  is  more  or  less  paresis  in  all  cases. 

Symptoms. — Sex  bears  important  relation  to  the  disease,  it 
being  found  much  more  frequently  in  the  female;  perhaps  the 
proportion  is  about  two  to  one.  Onset  occurs  most  frequently 
between  the  seventh  and  fourteenth  years.  The  adolescent  period 
has  something  to  do  with  the  development  of  the  cases  occurring 
latest  in  this  susceptible  epoch. 

The  first  symptom  is  generally  peevishness  of  the  child,  ac- 
companied by  general  restlessness,  which  the  mother  will  describe 
as  "  fidgets."  The  child  will  drop  an  object  without  any  apparent 
cause — e.  g.,  a  fork  at  the  table,  or  the  pencil  if  working  at  school. 
Within  a  week  the  movements  will  have  begun  in  the  arms,  face, 
tongue,  and  lower  extremities  in  the  typical  case.  The  move- 
ments are  very  irregular,  in  some  cases  tending  to  vermicular  mo- 
tion, but  never  in  any  degree  consistently  of  one  type.  The  pecul- 
iar contortions  of  the  face  give  the  child  a  grotesque  appearance, 
which  with  the  difficulty  of  speech  and  dribbling  of  the  saliva 
present  the  aspect  of  a  case  of  dementia  (facies  choreica).  This 
is  at  once  unwarranted  by  the  mental  condition  of  the  case  to  be 
described  later. 

The  gyrations  become  larger  and  increased  until  the  range  of 


FUNCTIONAL    NEEVOUS    DISEASES  279 

movement  may  extend  to  extreme  abduction  of  the  extremities,  the 
throwing  about  of  which  will  prevent  the  child  from  walking  or 
even  sitting  erect  from  mere  mechanical  disturbance.  In  other 
cases  the  palsy  is  so  much  greater  than  the  movements  that  they 
are  designated  the  "  paretic  type/'  In  these  the  patient  is  at  times 
absolutely  disabled,  with  a  few  movements  remaining.  In  other 
cases  the  irregular  movements  appear  well  marked  and  yet  are  asso- 
ciated with  palsy  out  of  proportion  to  the  motor  weakness. 

The  movements  of  chorea  cease  during  sleep.  They  are  much 
bettered  when  the  child  is  quiet,  and  are  exaggerated  on  physical 
or  mental  endeavour.  At  times  chorea  is  confined  to  one  side 
almost  exclusively,  which  type  is  termed  JiemicJiorea,  or  one  side 
of  the  body  may  be  affected  more  than  the  other.  Occasionally 
one  upper  extremity  and  the  opposite  lower  will  be  most  involved. 

The  child's  mental  condition  is  below  par,  and  while  sensitive, 
the  function  of  the  mind  is  singularly  obtunded,  memory  being 
poor,  with  inability  to  concentrate.  In  some  cases  there  is  mild 
ephemeral  dementia;  in  other  cases  the  dementia  may  go  on  to 
permanent  mental  impairment  or  death.  In  rare  instances  an 
excitable  condition  of  insanity  without  high  temperature  will 
occur. 

S.  Weir  Mitchell  divides  chorea  into  five  types,  as  follows: 
(1)  Those  with  absence  of  movements  during  rest,  during  some 
stage  of  the  disease.  (2)  Cases  in  which  continued  movements 
are  increased  by  effort.  (3)  Cases  in  which  movements  disappear 
during  intentional  muscular  acts.  (4)  Cases  unaltered  during 
muscular  acts.     (5)  Those  in  which  the  various  types  alternate. 

In  violent  cases  the  child  may  injure  himself  by  tossing  about, 
so  that  restraint  is  necessary.  The  only  somatic  symptom  of  im- 
portance is  feeble  and  irregular  cardiac  action.  In  75  per  cent  of 
cases  a  systolic  mitral  murmur  occurs,  either  hgemic  or  due  to  a 
mild  grade  of  endocarditis. 

The  duration  of  a  case  of  chorea  is  from  four  to  six  weeks. 
Severer  cases  may  last  many  weeks.  Eecurrences  are  quite  fre- 
quent, many  cases  having  relapse  in  the  spring  months  (March 
and  April),  or  in  the  early  fall  (September).  This  is  probably 
due  to  the  effect  of  the  changing  weather  as  well  as  to  overwork  at 
those  periods  of  the  year.  The  subsequent  attacks  are  generallv  not 
as  long  afe  the  primary  ones,  and  may  recur  from  two  to  fourteen 
times  in  as  many  years. 


280  TEEATISE    ON"    NEEVOUS    DISEASES 

As  the  patient  convalesces  from  the  attack  the  movements  grad- 
ually cease.  Frequently  when  the  paresis  is  very  prominent  the 
child  complains  of  greater  weakness  and  apathy  than  when  in  the 
attack.  The  movements  cease  last  in  the  face  and  tongue,  physio-- 
logically  the  most  sensitive  parts  of  the  body.  Extreme  ansemia 
will  at  times  develop,  a  cardiac  murmur  at  the  base  be  very  pro- 
nounced, and  even  fatty  degeneration  of  the  heart  muscle  be  shown 
by  the  feeble  contraction  of  the  myocardia.  In  some  cases  oedema 
of  the  lower  extremities  will  be  noted.  The  urine  is  generally  de- 
ficient in  chlorides,  with  excess  of  sulphates  and  phosphates,  show- 
ing the  waste  in  the  nervous  system;  while  indicanuria  is  a  fre- 
quent finding  in  those  cases  where  gastro-intestinal  fermentation 
exists,  as  a  complicating  factor  in  symptomatology  through  auto- 
intoxication. In  rheumatic  cases  the  mitral  cardiac  murmur  may 
be  very  persistent,  due  to  organic  disease  of  the  heart,  which  symp- 
tom may  dominate  in  the  case,  and  be  the  sequel  of  an  apparently 
mild  attack  of  chorea.  The  co-relation  of  rheumatism,  chorea,  and 
heart  disease  is  therefore  to  be  .borne  in  mind ;  while  a  patient  suf- 
fering from  rheumatic  pains  with  cardiac  disease  before  or  in  the 
attack  of  chorea  is  a  more  gravely  ill  person  than  one  not  having 
this  trio  of  signs.  The  knee-jerk  is  capricious  in  chorea,  fre- 
quently lessened,  and  always  easily  exhausted. 

Diagnosis. — Chorea  minor  is  not  likely  to  be  mistaken  for 
other  diseases.  Hysteria  may  simulate  this  disorder,  but  the  ex- 
plosive nature  of  hysterical  chorea,  the  larger  movements,  and 
less  palsy  will  distinguish  it.  HaMt  chorea  is  told  by  the  spas- 
modic and  localized  character  of  the  movements.  The  choreiform 
movements  of  the  cerehral  palsies  are  to  be  differentiated  by  noting 
the  other  signs  in  the  disease  in  question,  such  as  palsies,  increased 
reflexes,  etc.  Huntingdon  s  chorea  is  differentiated  by  its  occur- 
rence in  adult  life  and  its  association  with  mental  diseases;  also 
the  hereditary  nature  of  Huntingdon's  disease. 

Prognosis. — The  prognosis  of  chorea  is  good  in  the  vast  ma- 
jority of  cases.  A  usual  duration  is  six  or  eight  weeks.  The 
eases  with  cardiac  affection  are  more  apt  to  be  prolonged,  as  shown 
by  murmur,  even  if  the  heart  disease  is  functional;  also  the  ansemic 
cases  are  graver,  due  to  the  condition  of  malnutrition  of  the  cen- 
tral nervous  system  in  these  patients.  The  prognosis  in  cases  of 
organic  heart  disease  is  decidedly  bad,  both  as  to  recurrence  of  the 
chorea  and  as  to  the  life  of  the  patient,  since  with  each  succeeding 


FUNCTIONAL    NEEVOUS    DISEASES  281 

attack  of  chorea  of  a  severe  nature  the  systemic  failure  is  great. 
Such  patients  usually  die  of  organic  heart  disease  (endocarditis) 
within  two  to  five  years  after  the  original  attack  of  chorea.  The 
distinctly  atrophied  condition  of  the  mucous  membranes  in  these 
cases  is  shown  by  the  fact  that  portions  of  the  mucous  membrane 
of  the  nose  will  be  discharged  en  masse.  In  the  milder  cases  that 
recover  even  after  a  series  of  attacks,  the  patient  usually  grows 
into  vigorous  health,  no  condition  of  previous  cardiac  trouble  re- 
maining in  after-life. 

Treatment. — This  depends  upon  the  severity  of  the  disease. 
The  average  case  can  be  given  ambulatory  treatment.  Physical 
and  mental  rest  for  a  few  hours  each  day  is  essential,  as  is  qui- 
etude at  all  times,  and  fresh  air  and  sunlight.  The  child  should 
be  kept  away  from  exciting  influences  of  all  sorts,  particularly 
school ;  even  agreeable  excitement  is  harmful. 

The  emunctories  should  be  carefully  guarded.  Copious  draughts 
of  water  between  meals  are  indicated,  especially  in  cases  giving 
evidences  of  auto-intoxication.  The  diet  should  be  simple,  consist- 
ing largely  of  milk,  given  at  stated  intervals  (3  to  6  ounces  every 
three  hours  during  the  day)  ;  the  patient  can  also  be  given  whey, 
buttermilk,  largely  to  act  as  a  diuretic,  junket,  soft-boiled  eggs, 
bread  a  day  old,  and  the  lighter  meats,  avoiding  carbohydrates 
and  hydrocarbons,  which  disturb  digestion  in  these  cases. 

In  bad  cases  the  patient  should  be  put  to  bed  absolutely,  and 
where  the  movements  are  violent,  padding  about  the  bed  should 
be  judiciously  done  to  prevent  injury  to  the  patient.  Restraint 
will  sometimes  have  to  be  resorted  to  in  these  severe  cases.  Salt- 
water sponging  either  with  sea-water,  or  that  artificially  made  by 
placing  half  an  ounce  of  common  salt  to  a  quart  of  water,  at  a  tem- 
perature of  100°  F.,  will  be  a  soothing  measure,  when  applied  by 
sponging  for  five  minutes  twice  daily.  Light  effieurage  is  a  meas- 
ure assisting  in  soothing  the  nervous  system,  as  well  as  aiding  the 
circulation  and  bettering  the  nutrition. 

Among  drugs,  iron  is  indicated.  It  should  be  employed  espe- 
cially in  the  ansemic  cases  of  chorea.  In  children  the  tincture  of 
chloride  of  iron,  from  10  to  30  minims,  given  in  water,  three  times 
a  day,  is  of  great  value.  This  acts  as  a  stomachic  as  well  as  an 
hematic.  The  teeth  should  be  carefully  guarded  from  the  acid, 
rinsing  the  mouth  with  a  solution  of  hicarhonate  of  soda.  The 
French  pill  of  Blaud,  consisting  of  equal  parts  of  sulphate  of  iron 


282 


TREATISE    ON    NERVOUS.  DISEASES 


and  potassium  carbonate^  is  a  valuable  remedy.  In  my  experience 
this  pill  acts  better  in  the  older  cases.  The  treatment  of  the  disease 
per  se  is  principally  alterative,  and  no  remedy  acts  quite  so  well 
as  arsenic,  which  in  the  form  of  Eowler's  solution  is  pleasant  to 
take;  also  the  dose  can  be  nicely  graduated  to  the  necessity  of  the 
case.  The  usual  method  of  administration  is  by  giving  3  drops 
in  water  after  meals,  gradually  increasing  each  dose  by  one  drop, 
as  shown  in  the  accompanying  table : 


1st  day 

2d      "    

BREAKFAST. 

8  drops  

3       "     

DINNER. 

3  drops  

4       "     

SUPPEK. 

3  drops 

8       " 

3d      "    

4 

...     4       "     

3 

4th    "    

4 

4       "     

4 

5th    "    

.. 4 

5       "     

4 

6th    " 

5 

5       "      

4 

7th    " 

5 

6        "     

5 

8th    "    

6       "     

5 

9th    "    

6 

6       " 

5 

0th    "    

6 

6       "     

6 

etc. 


etc. 


etc. 


This  can  be  increased  to  15  or  25  drops.  When  the  physio- 
logical limit  is  reached  the  dose  should  be  reduced  one  half,  and 
kept  at  this  dosage  during  the  active  course  of  the  disease,  unless 
recurrence  of  the  arsenical  symptoms  are  noted.  In  some  persist- 
ent excitable  cases  the  use  of  the  bromides  is  indicated;  particu- 
larly the  ammonium  bromide  should  be  used,  since  it  is  less 
depressing  to  the  heart.  This  salt  will  be  found  of  special  benefit 
in  chorea  with  gastric  irritability.  Quinine,  antipyrine,  cimicif- 
uga,  and  sodium  salicylate  are  of  value  in  rheumatic  cases. 

The  cardiac  symptoms  should  be  very  carefully  guarded  in  a 
given  case.  Tincture  of  strophanthus  is  an  excellent  remedy  for 
deficient  compensation,  and  should  be  given  in  10-  to  15-drop 
doses  three  times  a  day  until  circulation  is  restored  to  the  normal. 
Where  serious  organic  heart  disease  complicates,  digitalis  should 
be  employed.  Long  rest  should  be  enjoined  after  the  chorea  has 
been  recovered  from.  Cod-liver  oil  is  a  valuable  reconstructive 
agent  to  be  employed  after  the  acute  attack  of  chorea  has  waned. 
It  is  often  desirable  to  change  the  scene  in  mild  cases  of  chorea. 
Sea  air,  where  high  winds  do  not  prevail,  is  desirable.  High  alti- 
tudes— above  2,000  feet — are  never  good  for  the  patient. 


FUNCTIONAL    NEEVOUS    DISEASES  283 

HABIT   CHOREA   OR    HABIT   SPASM 

This  is  a  disease  of  childhood,  having  its  origin  in  a  previous 
attack  of  simple  chorea  or  developing  primarily.  Heredity  plays 
an  important  part  in  the  (Etiology,  as  does  simulation  of  another 
case.  Children  of  robust  physique,  who  have  developed  a  simple 
chorea  of  very  active  type,  or,  indeed,  in  whom  the  chorea  has  been 
of  mild  form,  are  very  apt  to  be  those  who  will  have  a  habit  spasm 
remaining  after  the  simple  chorea  is  apparently  cured.  Other  ex- 
citing causes  of  the  development  of  primary  habit  chorea  are  reflex 
causes  of  many  sources,  such  as  e^^e-strain,  nasal  disease,  binding  or 
irritation  of  some  part  of  the  body  by  clothing,  a  phimosis,  seat 
worms,  deformities  of  speech  mechanism,  such  as  tongue-tie  or 
enlarged  tonsils,  or  anything  interfering  with  the  functionation  of 
the  unstable  nervous  system.  Thus,  a  boy,  with  the  predisposition, 
upon  donning  his  first  pair  of  "  suspenders  "  may  develop  shoulder 
twitching;  or  the  child  with  tongue-tie  may  begin  a  contortion  of 
the  neck,  induced  by  the  endeavour  to  speak  properly ;  or  blinking 
of  the  eyes  may  result  from  an  uncorrected  astigmatism. 

Symptoms. — The  parts  most  frequently  affected  in  habit  chorea 
are  the  eyelids,  facial  muscles,  neck  muscles,  and  shoulder-girdle 
muscles — parts  particularly  sensitive  in  their  nerve  supply.  The 
nature  of  the  movement  is  that  of  a  spasmodic  rather  than  true 
choreiform  motion,-  usually  excited  by  mental  or  physical  endeav- 
our, although  the  patient  can  frequently  control  the  movements  in 
part  by  the  will.  They  are  absent  during  sleep,  but,  unlike  simple 
chorea,  are  worse  when  the  attention  is  not  drawn  to  the  condition 
at  all.  Inhibition  of  the  movements  exists  more  decidedly  than  in 
simple  chorea,  in  the  latter  of  which  any  form  of  mental  action 
exaggerates  them.  As  inferred,  the  patient's  physical  vigour  is 
generally  excellent  in  cases  of  habit  spasm.  In  some  cases  where 
it  is  markedly  localized,  as  in  the  posterior  cervical  muscles,  they 
may  become  actually  hypertrophied  from  overuse  in  these  violent 
twitchings.  There  may  be  speech  defects,  such  as  echolalia,  where 
sounds  heard  are  reproduced;  coprolalia,  or  the  sudden  utterance 
of  profanity,  etc. 

Prognosis. — The  duration  of  the  disease  is  indefinite,  but  a 
favourable  prognosis  can  be  given  in  proportion  to  the  move- 
ments and  the  cases  resulting  from  previous  simple  chorea. 
Where  it  develops  from  some  other  exciting  cause,  as  peripheral 


;i84  TREATISE    ON"    NEEVOUS    DISEASES 

irritations^  in  my  experience,  the  disorder  is  sometimes  seen  last- 
ing for  years  or  becoming  incurable. 

Pathology. — This  is  not  known.  Irritability  of  the  upper 
motor  neuron  probably  exists  from  some  unknown  poison. 

Diagnosis. — It  may  be  confused  with  Sydenham's  chorea.  Per- 
sistency of  habit  spasm  distinct  from  typical  choreiform  move- 
ments, also  the  absence  of  rheumatic  history,  are  important  points. 
Habit  spasm  from  hysterical  chorea  is  distinguished  mainly  by 
stigmata  existing  in  the  latter  disease. 

Treatment. — This  consists  in  getting  rid  of  every  source  of 
irritation,  such  as  by  correcting  eyes,  by  circumcision,  extraction  of 
misplaced  tooth,  removal  of  enlarged  tonsils,  or  operation  for 
tongue-tie,  etc.  If  the  case  is  the  resultant  of  simple  chorea,  rest 
cure  and  tonics  are  principally  indicated.  Moral  influence  is  of 
vital  importance  in  the  therapeusis.  Hypnotism  is  a  means,  which, 
if  it  can  be  induced  in  the  subject,  is  a  quick  agent  towards  cure. 
A  valuable  measure  is  to  have  the  child  stand  before  the  looking- 
glass  for  three  to  five  minutes,  making  an  effort  to  control  him- 
self, and  in  this  way  educate  the  nerve-centres  to  proper  inhi- 
bition. Among  drugs,  the  use  of  bromides,  sparingly,  or  hyoscya- 
mus  may  be  of  value  until  the  nerve-centres  become  less  irritable. 
Proper  resort  to  bathing  is  a  valuable  measure,  and  should  be 
used.  The  cold  shower-bath  at  a  temperature  of  60°,  given  every 
morning,  will  do  much  towards  restoring  nervous  control  in  these 
cases,  largely  through  establishing  better  equalized  circulation 
within  the  central  nervous  system. 

HEREDITARY    CHOREA 

Synonyms:  Huntingdon's  Disease  or  Chorea 

This  is  a  disease  beginning  at  about  thirty  years  of  age,  more 
frequent  in  the  male  sex,  and  characterized  by  its  chronicity  and 
tendency  to  mental  affection.  The  hereditary  taint  of  this  mal- 
ady is  not  always  directly  in  the  ancestry,  but  there  is  always  some 
neural  vulnerability  or  cause  for  degeneration,  such  as  chronic 
alcoholism,  syphilis,  etc.,  in  the  immediate  progenitors.  The 
patient  in  the  onset  will  scarcely  have  been  seen  by  the  physician, 
but  it  will  be  reported  to  him  that  the  disposition  has  been  chang- 
ing for  some  months,  the  patient  having  become  nervous  and  irrita- 
ble, forgetful  and  perverse,  and  at  times  showing  violent  temper. 


FUNCTIONAL    NEEVOUS    DISEASES  '  385 

The  movements  generally  begin  in  the  upper  extremity,  are  larger 
in  the  gyrations  than  in  Sydenham's  chorea,  the  head  and  neck 
becoming  soon  affected,  and  with  the  movements  of  the  lower  ex- 
tremities the  gait  is  particularly  characteristic.  The  patient  in  his 
endeavour  to  walk  slides  and  pushes  one  limb  forward,  then  at- 
tempts to  draw  the  other  in  its  wake;  then  the  other  limb  will 
be  advanced  in  the  same  fashion,  thus  making  with  all  its  irregu- 
larity a  more  or  less  rhythmical  alternation  by  the  hampered  vol- 
untary effort.  The  movements  of  the  trunk  become  marked  within 
two  or  three  months.  These  may  cause  compression  of  the  abdo- 
men and  thorax.  Occasionally  involvement  of  the  diaphragm 
produces  sudden  explosive  sounds,  similar  to  echolalia  of  habit 
chorea.  The  mental  deterioration  will  have  been  well  manifest  by 
the  time  the  choreiform  movements,  etc.,  as  described,  begin.  This 
now  consists  of  periods  of  mental  depression,  alternating  with 
maniacal  tendency,  with  forgetfulness,  and  the  mental  status  tend- 
ing towards  dementia,  the  patient  using  finally  a  sort  of  jargon  in 
speaking,  entirely  distinct  from  the  mechanical  disturbances  of 
speech  which  also  exist,  due  to  the  involvement  of  the  pharyngeal 
muscles.  So  that  careful  observation  has  to  be  indulged  to  deter- 
mine in  foretelling  the  rapidity  of  downward  progress  of  the  case. 
The  tendency  to  suicide  is  a  characteristic  symptom  of  the  mental 
derangement.  The  patient's  movements  finally  become  so  exag- 
gerated that  he  cannot  walk  about,  the  irregular  choreiform  move- 
ments continued  during  the  waking  state,  which,  however,  entirely 
cease  when  the  patient  is  asleep.  The  movements  also  obey  those 
of  simple  chorea  in  regard  to  the  effect  of  mental  excitement, 
physical  endeavour,  etc.  The  movements  lessen  only  as  mental 
deterioration  progresses.  This  in  time  amounts  to  an  active  pare- 
sis, the  patient  becoming  bedridden  and  dying  of  some  intercurrent 
malady. 

Duration. — The  patient  may  be  a  sufferer  for  six  or  eight  years 
before  death  supervenes,  although  the  majority  of  cases  are  carried 
away  within  four  or  five  years  after  its  active  development. 

Diagnosis. — The  diagnosis  of  Huntingdon's  chorea  must  be 
made  between  it  and  simple  chorea,  or  liahit  chorea,  or  hysterical 
chorea.  The  age  of  the  patient,  the  recovery  and  relapses,  and 
history  of  rheumatism  and  milder  grade  of  movements  would  dis- 
tinguish the  simple  chorea.  The  localized  spasmodic  disorder  also 
occurring  in  children  without  any  mental  disturbances  would  dis- 


286  TEEATISE    OX    XEEVOUS    DISEASES 

tinguish  the  habit  eases.  H3'sterieal  chorea  would  be  known  by 
other  evidences  of  hj^steria,  the  vacillation  of  symptoms,  the  ab- 
sence of  dementia  and  suicidal  intent,  and  the  hysterical  chorea 
being  more  frequent  in  females. 

Prognosis.— This  is  absolutely  bad,  no  cases  having  been  in 
any  way  permanently  benefited. 

Pathology. — This  consists  of  congestion  of  blood-vessels  in  the 
cortex  of  the  brain  and  final  resultant  irritability  and  degenera- 
tion of  the  central  motor  neurones,  with  areas  of  softening  in  those 
cases  where  the  symptoms  and  signs  of  paresis  develop. 

Treatment. — The  treatment  of  the  disease  is,  as  far  as  known, 
therefore,  entirely  of  symptomatic  nature.  Supportive  measures 
is  the  first  desideratum.  A  simple  nutritious  diet,  consisting  of 
proteids  in  part,  such  as  red  meats,  oysters,  milk  and  eggs.  Excess 
of  carbohydrates  should  be  avoided  in  all  instances,  and  particu- 
larly in  those  where  there  is  a  diathetic  tendency,  such  as  to  rheu- 
matism or  rickets.  The  system  should  be  kept  well  flushed  with 
water  to  prevent  the  retention  of  autochthonous  and  other  forms 
of  poisons,  particularly  absorption  of  ptomaines  from  the  intes- 
tinal tract.  The  use  of  iodide  of  potassium  or  salicylate  of  soda,  in 
small  doses,  is  indicated  where  uric-acid  retention  is  suspected. 
Such  nutrients  as  cod-liver  oil  and  hypophosphites  and  the  lime- 
salts  are  valuable  adjuvants.  A  pill  of  phosphorus,  y]j -g-  of  a  grain, 
or  extract  of  chirata,  1  grain,  thrice  daily,  are  of  service.  Tincture 
of  hyoscyamus  or  tincture  of  conium  are  antispasmodic  medica- 
ments that  are  sometimes  of  value  in  controlling  the  movements. 
The  careful  use  of  bromides  to  overcome  the  restlessness  and  gen- 
eral irritability  is  desirable.  Hypodermic  injections  of  hyoscine 
hydrobromate,  yftr  of  a  grain,  increased  to  --Vj  acts  markedly  well 
in  cases  with  maniacal  disposition.  Patients  should  be  constantly 
guMTded  as  to  the  possibility  of  committing  suicide,  and  if  paresis 
becomes  a  prominent  and  permanent  symptom,  it  will  become 
essential  to  commit  the  patient  to  a  hospital  for  the  insane. 

CONVULSIVE   TIC 

Synonyms:  Tremor,  or  Oiles  cle  la  Tourette's  Disease 

This  is  an  afPection  characterized  by  large  irregular  choreiform 
movements,  involving  the  face  and  neck,  at  times  affecting  other 
parts  of  the  body,  and  which  may  become  general.    It  is  also  char- 


FUXCTIOXAL    XEKTOUS    DISEASES  28t 

acterized  by  large  movements,  and  further  by  peculiar  mental  dis- 
order. Heredity  is  a  strong  predisposing  factor  in  this  disease. 
Fright  or  shock  is  the  most  frequent  exciting  cause.  By  some  au- 
thorities it  is  designated  a  psychosis,  similar  to  hysteria.  It  usu- 
ally begins  in  early  childhood,  and  is  accompanied  by  three  promi- 
nent sets  of  manifestations.  First,  the  involuntary  movements, 
given  in  the  definition — these  being  extreme  contortions  of  the 
part  rather  than  any  typical  form  of  movement.  The  face  is 
thrown  into  a  most  grotesque  physiognomy.  The  head  is  rotated 
and  moved  about  irregularly  upon  the  shoulders.  In  semiclonic 
spasm  the  movements  extend  first  to  the  shoulders,  causing  a  spas- 
modic shrugging,  depression,  and  throwing  back  of  the  same.  The 
trunk  is  finally  involved  in  the  spasm,  and  at  length  the  extremities 
may  be  the  seat  of  the  wildest  movements.  All  of  these  are  exag- 
gerated by  excitement  or  voluntary  muscular  effort.  At  times  the 
spasm  is  so  great  that  the  patient  may  be  thrown  to  the  ground. 
Peculiar  involuntary  sounds  are  emitted,  due  to  the  spasm  of  the 
glottis  and  pharyngeal  muscles.  These  echolalia  or  coprolalia 
may  be  manifested  in  sudden  exclamations.  The  mental  disturb- 
ance consists  of  morbid  fears,  of  doubt  (misophobia),  of  disease 
(pathophobia),  etc.  Morbid  impulses  such  as  erotomania  exist. 
Imperative  movements  may  be  attempted,  but  are  usually  frus- 
trated by  the  involuntary  retraction  of  muscles.  The  patient  may 
finally  become  extremely  delusional  and  pass  into  chronic  terminal 
dementia,  accompanied  by  wasting  of  all  the  muscles.  Death  from 
exhaustion  will  then  supervene. 

Diagnosis  should  be  made  from  hysterical  affections  without 
difficulty,  and  would  be  clarified  upon  noting  the  persistent  down- 
ward course  of  convulsive  tic  without  the  remissions  of  hysteria. 

Prognosis  is  absolutely  bad,  there  being  no  instances  of  bet- 
terment through  any  forms  of  treatment.  The  malady  is  an 
acute  form  of  degeneration  of  the  nervous  system,  a  diffuse  lesion 
being  found  in  the  central  neurones,  although  of  no  definite  dis- 
tribution in  any  particular  part. 

SALTATORY    SPASM 

Synoxym:  Jumper  s  Disease 

This  is  a  neurosis  allied  to  hysteria,  occurring  in  early  adult 
life  in  endemic  form,  often  due  to  the  simulation  of  other  cases 
of  the  disease,  and  characterized  by  sudden  violent  spasms  of  the 


288  TEEATISE    ON    XervOUS    DISEASES 

flexor  muscles  of  the  thighs  and  calves  in  particular,  which,  in 
contraction,  produce  the  typical  symptoms  of  the  disorder — a 
series  of  skips  or  jumps,  keeping  up  for  a  few  moments,  and  finally 
ending  in  enfeeblement  or  collapse  of  the  patient,  again  to  he 
renewed  upon  recovery.  These  remissions  may  occur  many  times 
during  the  twenty-four  hours,  the  patient  after  each  seance  becom- 
ing utterly  exhausted.  Then  a  disturbed  sleep  will  follow  the  at- 
tack. Biit  the  "  jumping  "  begins  on  waking.  The  duration  of 
the  attack  or  of  the  affection  is  indefinite.  Both  are  pretty  much 
in  proportion  to  proper  treatment  instituted.  Such  cases  quite  fre- 
quently develop  during  religious  revivals,  and  will  disappear  after 
the  excitement  is  over.     Some  may  die  of  exhaustion. 

Pathology. — There  is  nothing  known  of  the  pathology.  G-iven 
an  emotional  subject,  such  irritability  of  the  motor  neurones  may 
be  set  up  by  excitement ;  the  only  clue  we  have  to  pathogenesis. 

Diagnosis. — This  is  made  clear  by  observing  the  endemic  form 
of  the  disease,  the  peculiar  paroxysms,  and  the  hysterical  mental 
aspect. 

Prognosis. — This  is  good.    Most  cases  should  recover. 

Treatment. — Cure  depends  upon  the  ability  to  gain  control  of 
the  patient  and  to  impress  his  moral  and  mental  nature.  Hyp- 
notism is  a  valuable  therapeutic  measure  in  this  disorder,  for,  if 
the  patient's  mind  can  be  concentrated  enough  to  subject  him 
to  hypnosis,  the  ease  can  generally  be  turned  towards  a  rapid 
cure.  The  separation  of  the  patient  from  the  predisposing  cause, 
or  from  others  affected  with  the  same  malad}^,  is,  of  course, 
to  be  insisted  upon.  Such  conditions  are  allied  to  the  hysteria 
observed  in  the  northern  coal  regions  of  Pennsylvania  four  or  five 
years  ago,  as  investigated  by  Professor  Newbold,  of  the  Univer- 
sity of  Pennsylvania. 

THOMSEN'S    DISEASE 

Synonyms:  Paramyoclomis  multiplex;  Ilyotonia  congenita;  Myospasm  or 
Convulsive  tremor. 

It  is  a  congenital  and  inherited  disease  of  the  muscles,  which 
is  manifested  by  irregular  bilateral  spasmodic  contractions  of  the 
muscles,  5  to  120  a  minute,  either  in  groups  of  muscles  in  the 
extremities,  or  involving  all  the  muscles  of  the  body.  The  disease 
appears  earlier  in  life  than  the  preceding,  starting  in  early  child- 


FUNCTIONAL    NEEVOUS    DISEASES  289 

hood,  is  much  more  frequent  in  the  male  sex,  and  is  of  hereditary 
nature.  Tlie  patient  while  sitting  will  suddenly  develop  violent 
spasms .  of  a  part  which  may  be  sufficient  to  dislodge  him  from 
the  sitting  posture,  or,  if  in  progression,  may  cause  him  to  tumble 
about  or  fall.  The  muscular  contractions  are  accompanied  by 
slight  pain,  but  there  is  no  tenderness  over  the  muscles,  and  dur- 
ing the  time  of  contraction  they  stand  out  in  great  prominence. 
The  movements  are  generally  quieted  by  rest,  and  are  altogether 
absent  during  sleep,  although  the  spasms  themselves  prevent  som- 
nolence in  many  cases.  There  is  not  the  m^ental  deterioration  that 
is  seen  in  convulsive  tic. 

Exercise  or  catching  cold  aggravates  the  spasm. 

Pathology. — Little  is  understood  of  pathogenesis,  and  save  for 
the  hypertrophy  of  the  muscle  fibres  and  the  constant  prolifera- 
tion of  the  muscle  nuclei,  nothing  is  definitely  known  of  the 
pathology.  The  duration  may  be  ten  or  -fifteen  years,  the  patient 
finally  succumbing  to  intercurrent  disease. 

Diagnosis. — It  cannot  be  mistaken  for  other  maladies  on  care- 
ful study  of  the  above  outlined  semeiology. 

Treatment. — Massage,  Swedish  movements,  and  hot-water  bath- 
ing are  methods  of  relaxing  the  muscles.  Nutritive  measures, 
the  hypophosphites  among  drugs  being  of  value  in  keeping  up  the 
tone  of  the  nervous  system.  Protonuclein  may  be  of  service 
through  supplying  nuclein  to  the  degenerating  muscle  cell  (gr. 
V,  t.i.d.). 

EPILEPSY 

Definition  and  JEtiology. — Epilepsy  is  a  neuro-psychosis  in 
which  unconscious  attacks  and  a  tendency  to  convulsive  seizures 
are  permanent  features  of  the  disorder.  The  disease  is  well  known 
to  be  hereditary  as  to  the  degenerative  predisposition;  and  it  will 
frequently  be  found  that  where  epilepsy  has  not  existed  in  the 
previous  generation  there  will  at  least  be  a  history  of  alcoholism 
or  specific  disease  in  the  ancestry.  The  disease  may  occur  at  any 
period  of  life.  In  those  more  truly  hereditary  eases  (75  per  cent) 
it  begins  quite  early,  before  the  tenth  year.  The  sexes  are  about 
equally  affected.  It  can  be  pretty  positively  stated,  the  more  ad- 
vanced the  age  at  the  development  of  the  disease  in  the  so-called 
idiopathic  case,  the  less  likelihood  of  heredity  being  an  setiological 
factor ;  but  up  to  the  degenerative  period  of  life,  when  inhibition 
19 


290  TEEATISE    ON   NERVOUS    DISEASES 

is  less  stable,  epilepsy  may  appear  as  real  stigmata  of  a  degenera- 
tive tendency.  Other  causes  of  epilepsy  are  mental  shock,  injury 
to  the  head,  such  as  fractures,  concussion  or  compression  of  the 
brain,  meningitis,  brain  tumour,  gunshot  wounds,  toxsemias  (alco- 
hol, lead,  diabetes,  uraemia),  reflex  irritation  (eye-strain,  phimo- 
sis, nasal  or  intestinal  disease),  and  circulatory  disturbances.  Cor- 
tical apoplexy  or  meningeal  haemorrhage  is  not  infrequently  the 
fundamental  cause  of  the  epilepsy  coming  on,  due  to  insuperable 
obstacles  at  birth;  and  in  such  cases  the  epileptic  disease  is  but  a 
symptom  of  the  cerebral  palsy  of  childhood.  This  is  well  marked 
in  the  case  of  a  boy  under  the  writer's  care  who  is  spastic,  has  a 
dolichocephalic  head,  has  had  convulsions  since  babyhood,  and  has 
from  three  to  ten  attacks  of  grand  mal  daily.  He  frequently  suffers 
from  post-epileptic  palsy.    Hydrocephalus  is  a  cause  of  epilepsy. 

Diagnosis  and  Symptoms. — Epilepsy  is  divided  into  major 
{grand  mal)  and  minor  attacks  (petit  mal). 

Major  epilepsy  is  divided  into  focal  or  Jacksonian,  where  the 
spasm  is  limited  to  a  part  or  member  of  the  body,  or  where  the 
convulsive  seizure  begins  locally.  There  are  also  general  epileptic 
convulsions.  AVhere  the  disease  is  well  established  there  is  present 
a  peculiar  physiognomy,  one  of  mental  depression  and  instability  of 
purpose;  also  acne  on  the  face,  as  a  rule,  the  result  of  prolonged 
use  of  bromides — the  so-called  epileptic  fades  when  associated 
with  the  features  of  mental  instability  mentioned. 

Premonitory  symptoms  frequently  precede  the  attack.  These 
consist  of  headache,  giddiness,  jerkings,  mental  depression  or  ab- 
erration, etc.,  and  may  occur  for  some  hours  before  the  attack. 

The  attach  may  be  ushered  in  by  a  peculiar  subjective  sensation 
called  an  aura;  usually  a  globus  or  a  feeling  of  depression,  as  of  a 
cloud  coming  over  the  patient,  the  vision  becoming  dull,  and  in  a 
moment  passing  into  the  convulsion.    There  are  many  aurse. 

Senso7-y  Aurce. — The  aura  may  also  be  a  pain  in  the  epigas- 
trium— gastric  aura;  or  rarely,  it  may  be  of  paresthesia  in  an 
extremity;  or  less  frequently,  an  hallucination  of  smell  or  taste 
or  hearing  or  sight.  I  have  known  a  ease  where  the  odour  of 
violets  preceded  the  attack;  another  in  which  the  sound  of  the  disr 
charge  of  a  gun  was  the  hallucination;  while  irregular  scotoma 
or  the  seeing  of  some  grotesque  object  may  be  the  visual  disturb- 
ance preceding  the  seizure.  Motor  aura  as  a  marked  tremor  may 
occur.     Following  this  there  may  or  may  not  be  irregular  auto- 


FUNCTIONAL    NERA^OUS    DISEASES  291 

matic  movements  in  different  parts  of  the  bod}^,  the  patient  quickly 
becoming  pale,  then  cyanotic  and  unconscious.  In  the  light 
attack  (petit  mal)  the  patient  may,  with  or  without  this  precedent 
phenomena,  pass  into  unconsciousness,  accompanied  by  dilatation 
of  pupils,  and  if  at  table,  dropping  the  fork  or  some  other  object 
— the  spell  lasting  but  a  few  seconds,  when  the  patient  may  resume 
his  usual  condition.  The  attack  may  be  succeeded  by  somno- 
lence or  sound  sleep  lasting  a  half  hour  or  more.  In  case  the 
attack  is  one  of  grand  mal  succeeding  the  premonitory  signs 
already  mentioned,  or  with  the  initial  cry  in  most  cases,  due  to 
the  firm  rigidity  of  muscles  of  the  chest,  the  patient  falls  over 
unconscious  and  goes  into  a  general  convulsive  seizure,  consisting 
of  tonic  rigidity  followed  by  clonic  spasms  accompanied  by  froth- 
ing at  the  mouth  and  conjugate  deviation  of  the  eyes  up  and  out 
towards  the  side  of  most  violent  movements;  also  dilated  pupils. 
Blood  may  also  be  seen  coming  from  the  mouth,  due  to  biting  the 
tongue  in  the  attack.  The  convulsion  finally  ends  by  rigidity  of 
the  flat  trunkal  muscles,  and  within  a  minute  or  so  the  entire 
attack  is  completed,  there  being  rather  sudden  restoration  of  con- 
sciousness and  of  power  in  the  extremities,  although  the  intellect 
remains  especially  dulled  for  some  moments,  and  there  may  be 
transient  aphasia.  The  patient  here  again  is  apt  to  go  into  som- 
nolence, which  may  last  half  an  hour, or  several  hours  in  rare  cases; 
but  exceptionally  post-epileptic  paralysis  may  occur  or  automatic 
acts,  the  patient  going  about  without  mental  control  or  apprecia- 
tion of  his  surroundings.  In  an  attack  the  patient  usually  suffers 
vesical  or  rectal  incontinence,  or  both. 

Occasionally  "  masked  epilepsy "  or  substitution  phenomena 
take  place  of  the  attack  per  se,  the  patient  passing  through  auto- 
matic acts  instead  of  a  convulsion;  or  a  condition  of  double  con- 
sciousness may  exist  in  which  the  patient  may  wander  off  for  some 
hours  or  days,  "  coming  to  himself  "  in  a  remote  locality.  This  is 
termed  ambulatory  epilepsy.  Rarely,  too,  some  marked  ps3^chosis 
may  be  the  substitution,  as  a  mania  or  delusional  insanity  with 
homicidal  or  suicidal  tendencies.  If  the  attacks  follow  one  upon  the 
other  in  rapid  succession, M^e  have  what  is  termed  status  epilepticus, 
and  in  such  condition  the  patient  may  actually  die  of  exhaustion. 

The  epileptic  complains  of  soreness  and  pain  in  the  limbs  after 
a  seizure,  and  the  body  mav  be  bruised  or  dislocations  oc'cur  from 
the  movements  or  in  the  falling  at  the  beginning  of  the  attack. 


292  TREATISE    OX    XEEYOUS   DISEASES 

Convulsions  occur  more  frequently  in  the  early  morning  hours 
when  the  patient  is  asleep;  this  is  probably  due  to  the  lowered 
physiological  ebb  of  the  nervous  system  at  this  time.  In  chronic 
cases  this  rule  will  not  be  maintained;  the  patient  will  have  the 
attack  at  any  part  of  the  day  {diurnal)  or  hour  of  the  night.  If  it 
be  nocturnal  epilepsy^  frecjuently  the  patient  is  not  aware  of  the 
atiack  except  for  the  soreness  in  the  muscle.  Intercurrent  diseases 
or  pregnancy  may  stay  attacks  for  the  time  being. 

Gowers  mentions  the  following  as  the  chief  characteristics  of 
Ijetit  mal,  arranged  in  the  order  of  frequency : 

1.  Sudden    momentary   unconsciousness,    or    "  fainting/'    or 
"  sleepiness/'  without  warning. 

2.  Giddiness. 

3.  Jerks  or  starts  of  the  limbs,  trunk,  or  head. 

4.  Visual  sensations  or  loss. 

5.  Mental  state:  Sudden  sense  of  fear,  etc. 

6.  Unilateral  peripheral  sensation  or  spasm. 

7.  Epigastric  sensation. 

8.  Sudden  tremor. 

9.  Sensations  in  both  hands. 

10.  Pain  or  other  sensation  in  the  head. 

11.  Choking  sensation  in  the  throat, 

12.  Sudden  scream. 

13.  Olfactory  sensation. 

14.  Cardiac  sensation. 

15.  Sensation  in  nose  or  eyeball. 

16.  Sudden  dyspnoea. 

17.  General  '^  indescribable ''  sensations. 

After  these  attacks  patients  may  perform  automatic  actions,  as 
after  attacks  of  grand  mal.  Eating  at  times  induces  attacks  re- 
flexly. 

Convulsions  usually  sooner  or  later  develop,  and  the  two  forms 
often  coexist  and  interchange  in  the  nature  of  attacks.  In  either 
form  of  epilepsy  there  is  excess  of  leucocytes  and  poikilocj^tes. 

Diagnosis. — Epilepsy  may  be  confused  with  the  hysterical 
paroxysm  in  rare  cases.  In  hysteria  there  are  stigmata  of  the 
/"'disease,  such  as  reversed  colour  fields,  hystogenic  zones,  etc. ;  and 
the  attack  itself  is  prolonged  a  half  hour  or  more,  the  spasms 
being  more  irregular  and  tonic  in  character.  The  patient  bites 
the  lips  rather  than  his  tongue.     The  eyelids   are  kept  closed. 


FUNCTIONAL    NEEVOUS    DISEASES  293 

The  pupils  are  not  dilated.    Syncopal  attacks  may  resemble  petit 
mal.     Careful  study  of 'the  circulation  will  differentiate. 

Puerperal  convulsions  are  told  by  the  history  of  the  case,  the 
finding  of  albumin  in  the  urine,  and  the  more  prolonged  series 
of  convulsions.  Other  symptomatic  epilepsies  are  easily  diagnos- 
ticated. Myoclonic  epilepsy  is  told  by  the  preceding  myoclonic 
state  of  the  muscles. 

Pathology. — This  is  most  likely  a  subtle  anatomic  or  physio- 
logical affection  of  the  cerebral  cortex  in  all  cases,  though  careful 
search  in  the  majority  of  so-called  idiopathic  cases  fails  to  reveal 
any  changes  by  our  present  methods  of  research,  which  only  goes 
to  show  our  profound  ignorance  of  this  enigmatic  disease.  If  a 
patient. dies  in  convulsion,  venous  engorgement  and  minute  haem- 
orrhages may  be  found  in  the  cortex.  Diffuse  sclerosis  of  the 
cortex  has  been  found  (tuberculous  or  otherwise),  meningo- 
encephalitis. Fere  has  frequently  found  neuroglear  prolifera- 
tion, while  Marenesco  and  Block  have  described  vascular  and  peri- 
vascular changes  in  the  cortex.  Hypertrophy  of  neuroglear  bun- 
dles between  pia  and  cortex  is  very  frequent.  .Organic  epilepsy  will 
have  as  its  pathology  the  pathology  of  the  causative  disease. 

Prognosis. — An  axiom  in  prognosis  of  epilepsy  is,  that  the 
younger  the  case  the  worse  it  is  for  help  or  cure;  the  older  the 
person,  per  contra,  the  greater  hope  for  amelioration  or  recov- 
ery. Among  the  latter  class  we  have  subdivisions:  first,  cases  in 
which  mental  degeneration  takes  place  rapidly;  and  secondly, 
those  where  the  attacks  do  not  seem  to  produce  any  great  mental 
depreciation.  Napoleon's  case  was  an  example  of  this  class. 
Focal  epilepsies  are  pretty  positively  due  to  some  definite  organic 
lesion.  In  proportion  as  the  cerebral  cortex  itself  is  involved  will 
surgical  aid  fail  of  relief.  But  where  such  lesion  is  operable,  as, 
for  example,  a  localized  meningeal  lesion  or  depressed  fracture, 
operation  at  the  earliest  moment  will  be  fraught  Avith  relief  or 
cure  in  15  per  cent  of  cases,  x^f  ter  five  years  surgery  cannot  help 
epilepsy,  since  the  habit  has  been  too  deeply  established.  In  pass- 
ing, it  should  be  stated  that  extradural  haemorrhage  in  the  newly 
born  ought  to  be  treated  surgically,  if  sequent  epilepsy  from  a' 
secondary  irritation  is  to  be  avoided  in  later  life.  Such  surgical 
procedure  has  as  yet  never  been  done,  but  has  been  suggested  by 
Dr.  S.  Weir  Mitchell  and  Dr.  W.  W.  Keen.  As  refinements  of 
diagnosis  become  more  and  more  accurate  in  the  new-born  will  the 


294  TEEATISE   OF  NERVOUS   DISEASES 

possibility  of  such  help  from  the  surgeon  be  determined.  Spon- 
taneous cures  rarely  occur.  If  attacks  have  lasted  two  years,  there 
is  little  hope  of  cure  in  "  idiopathic  "  cases. 

Treatment. — The  above-indicated  surgical  treatment  we  most 
earnestly  commend  in  early  cases  of  the  disease  where  there  is  any 
evidence  of  dural  hgemorrhage,  or  other  foreign  body  causing  irri- 
tation of  the  cortex.  A  child  with  epilepsy  should  be  subject  to 
most  rigid  scrutiny  for  evidences  of  reflex  irritations.  Gastro- 
intestinal disord,ers,  including  those  due  to  parasites,  as  the  nema- 
todes or  trematodes,  should  be  eradicated  by  first  expelling  the 
offending  parasite.  The  use  of  depresso-motors  is  indicated  in 
epilepsy,  since  there  is  excitation  of  the  motor  cortex;  such  symp- 
tomatic treatment  is,  of  course,  to  be  desired  in  itself,  and  these 
drugs  do  much  good  in  this  disease.  Ten  to  15  grains  of  the 
bromide  of  potassium  should  be  given  three  to  four  times  a  day, 
according  to  the  age  of  the  patient  and  the  physiological  idiosyn- 
crasy. In  giving  the  bromides,  they  should  be  continued  for  a 
month  or  two,  when,  even  if  the  attacks  are  stayed,  it  is  wise  to 
withhold  the  drug  for  a  week,  then  to  continue  with  small  doses, 
gradually  getting  up  to  the  maximum,  as  mentioned.  The  opium 
treatment  of  epilepsy,  which  consists  in  the  gradual  increase  of  the 
drug  up  to  producing  stupor  in  the  patient,  has  been  commended 
by  Collins  in  this  country  and  by  Flechsig  and  others  abroad. 
The  tendency  to  disturb  the  stomach  of  the  patient  or  to  produce 
the  morphine  habit  seems  to  me  a  strong  contra-indication  against 
the  use  of  the  drug ;  although  I  have  seen  a  hypodermic  injection 
of  morphine  sulphate  given  during  an  epileptic  status  quiet  the 
patient  and  prevent  further  seizures  for  the  time  being.  The  use 
of  cannabis  indica  will  be  found  of  value  in  cases  of  petit  mal. 
The  berries  of  the  horse-nettle  or  Solanum  carolinense,  especially 
in  the  form  of  the  fluid  extract,  I  have  found  beneficial  in  a  num- 
ber of  cases  of  idiopathic  epilepsy  where  there  is  no  hereditary 
taint.  A  fluid  extract  of  the  drug  is  particularly  serviceable  if 
made  from  fresh  berries,  the  drug  being  pushed  to  the  full  physio- 
logical limit.  At  present  in  a  case  under  this  form  of  treatment, 
after  all  other  methods  have  failed,  a  fluid  extract  of  the  berries, 
pushed  to  a  dram  four  times  a  day,  has  prevented  an  attack  for 
three  months,  whereas  the  girl  had  been  havinsr  them  previously  on 
an  average  of  one  attack  every  ninth  day.  Belladonna  is  occasion- 
ally a  useful  remedy,  especially  where  the  circulation  seems  to 


FUNCTIOITAL    NERVOUS    DISEASES  295 

have  failed  through  vaso-contraction ;  this  in  conjunction  with 
nitroglycerin,  given  in  continued  dosage,  will  sometimes  act 
favourably  in  allaying  the  spells.  The  use  of  digitalis  in  combina- 
tion with  the  bromides  has  controlled  attacks  in  many  cases  with 
feeble  heart  circulation,  where  the  bromides  alone  had  failed.  The 
reason  of  this  lies  perhaps  in  the  better  circulation  produced  in  the 
brain,  as  well  as  in  the  more  active  circulation  carrying  off  waste 
products.  In  all  cases  of  epilepsy  the  gastro-intestinal  tract  should 
be  particularly  guarded.  If  indican  be  found  in  excess  in  the 
urine,  especially  is  it  important  to  use  intestinal  antiseptics,  such  as 
salol,  grains  2  to  4,  in  twenty-four  hours ;  also  high  flushings  of  the 
colon  with  lime-water  solution,  an  ounce  to  a  quart  of  tepid  water. 
If  there  be  gastric  dilatation,  lavage  of  the  stomach  will  frequently, 
by  preventing  absorption  of  undigested  food  products  into  the 
blood,  produce  happy  results.  Regulated  exercise  is  essential. 
The  mind  should  be  lightly  employed.  Special  care  should  be 
given  to  massage  and  the  hygienic  condition  of  the  skin ;  salt  bath- 
ing is  particularly  desirable  to  stimulate  cutaneous  circulation,  and 
to  the  full  extent  relieve  any  congestion  of  the  meninges.  Tou- 
louse speaks  of  the  value  of  withdrawing  common  salt  from  epi- 
leptics, thereby  permitting  free  absorption  of  the  bromides.  Dis- 
turbed metabolism,  especially  the  uric-acid  diathesis,  calls  for 
careful  attention ;  and  in  the  latter  class  of  cases  the  use  of  alkaline 
waters  is  to  be  commended.  Milk  diet,  or  at  least  the  withhold- 
ing of  meats  and  indigestible  foodstuffs,  is  important.  The  worst 
cases  are  better  treated  in  the  colony  farms,  as  at  Sonyea,  N.  Y. 

NEURASTHENIA 

Synonyms:  Nervous  exhaustion;  Nerve  tire;  Nervous  prostration ;  Beard's 

disease. 

Definition. — This  is  a  functional  disease  in  which  there  is  a 
condition  of  irritability  with  weakness  of  the  central  nervous  sys- 
tem. It  was  first  described  by  Beard,  of  New  York,  in  1869.  The 
age  of  onset  is  usually  between  eighteen  and  thirty  years.  It  is 
more  frequent  in  women  (75  per  cent  of  the  cases),  more  persistent 
when  occurring  in  the  male.    The  disease  is  hereditary  or  acquired. 

Causes. — Overwork,  worry,  hereditary  predisposition,  poisons, 
autoinfections,  and  fright.  Other  predisposing  causes  are  ane- 
mia and  sedentary  habits,  lack  of  exercise,  unhygienic  surround- 


296 


TREATISE    OX    XEEVOUS    DISEASES 


ings,  absence  of  sunlight,  improper  food,  and  genital  disease,  par- 
ticularly in  women.    (See  Fig.  64.) 

The   communications   of  the  nervous  system  to  the   genital 
organs  may  be  better  understood  by  the  following  diagram: 


Spinal  eord. 


Plexus  luchiadicus  Plex.padendaliS  Plexu.i  coccygeus    Plexus  deo-inguinal.   .  plexus  genito  crural. 


y.n.  Iieii 
iXerves  of  lower 
extremities) 


\  I 


.V.  spennUnt.       N.  lumbo-inguinalis 


Branches  to  uterus 
\ 
\ 
\ 


y.,perinealis  I  -Y.  dorsal  clit. 
\  I 

\  ' 

Fleu:iis  aavernoaus  {cHtoria) 
\  \  # 


Plexus  vesico-vaglnalis 
(Bladder  and  vagina) 


Plexus  utero-vaginalia 
'( Uterus  and  vagina) 


Plexus  spermat  (ovaries,  tubes 
and  fund,  uteri) 

\^  Plexus  renalis  iovaries) 
Plexus  Ccdiacus 

Tig.  64. — Communications  of  the  Neryocs  System  to  the  Genital  Organs. 
Dotted  lines  indicate  combinations.     (Pearce-Beyea.)' 

From  this  description  it  is  definitely  shown  that  there  is  an 
anatomical  relation  between  the  female  genitals  and  the  nervous 
system,  and  it  would  seem  that  there  must  be,  at  least  in  some 
measure,  a  communication  between  certain  physiological  functions 
and  diseases  of  the  female  genitals  and  the  nervous  system;  and 
also,  therefore,  to  some  diseases  of  the  nervous  system. 

Symptoms — Psychic. — Generally  an  irritability  of  the  mind, 
lack  of  power  of  concentration,  f orgetfulness  and  inability  to  carry 
on  a  continuous  line  of  thought;  peevishness,  and  supersensitive- 


The  Memphis  Lancet,  September,  1898. 


FUKCTIOXAL    XEETOUS    DISEASES  297 

ness,'  with  insomiiia.  The  patient  complains  of  vertigo.  Photo- 
phobia or  other  special  sense  irritability  may  be  manifest.  The 
bladder  may  be  "  irritable  "'  and  an  early  symptom. 

Sensory. — Peculiar  sensations  exist  as  of  heat  and  cold,  parses- 
thesia  of  the  extremities,  or  actual  hypersesthesia.  There  are 
usually  tender  spots  on  pressure  over  the  spinal  column,  princi- 
pally over  the  cervical,  dorsal,  and  lumbar  enlargements  of  the 
cord.  The  patient  complains  of  a  sense  of  constriction  about  the 
head,  a  vague  feeling'  of  distress,  often  described  as  a  "helmet- 
like" headache.  The  pain  may  be  localized  particularly  in  the 
frontal  and  occipital  regions.  It  is  made  worse  by  use  of  the  eyes 
and  by  mental  or  physical  work.     Backache  is  constant. 

Motor. — These  consist  of  a  fine  tremor  of  the  extremities,  and 
tongue,  and  lips.  The  tremor  is  brought  out  by  intention.  It 
is  apt  to  subside  when  the  patient  is  quiet  in  the  milder  cases. 
The  muscular  tone  is  lessened,  fibrillary  contractions  of  the  mus- 
cles may  occur,  especially  if  tapped  with  the  percussion  hammer, 
that  may  bring  this  phenomenon  out  enough  to  simulate  the  fibril- 
lary contraction  of  degenerative  states,  as  in  chronic  poliomyelitis. 
There  is  widespread  enfeeblement  of  the  musculature.  The  patient 
tires  on  the  slightest  exertion,  but  there  is-  never  palsy  or  convul- 
sion.   The  reflexes  are  heightened.    Weakness  is  worse  before  noon. 

Yaso-moior  palsy  and  leakiness  of  the  skin  with  cold  extrem- 
ities is  frequent.  Palpitation  of  the  heart  is  not  uncommon.  The 
urinary  secretion  is  usually  increased  and  of  low  specific  gravity, 
with  excess  of  phosphates.  Indicanuria  is  very  general  in  cases  of 
gastro-intestinal  origin.  Colliquative  diarrhoea  is  a  common 
symptom,  although  it  may  alternate  with  persistent  constipation. 
The  patient  often  complains  of  tympanites,  borborygmus,  and 
tenesmus.  Hyperchlorhydria  is  not  uncommon,  and  is  especially 
marked  after  a  meal.  In  some  cases  there  is  distinct  gastrectasia. 
Displacements  of  the  abdominal  organs  will  be  found  in  a  few 
cases  of  neurasthenia;  thus  floating  kidney  is  not  a  rare  occur- 
rence; displacement  downward  of  the  liver  we  have  seen,  due 
entirely  to  the  relaxation  of  its  ligaments.  The  occurrence  of 
abdominal  pain  in  the  right  lower  quadrant  of  the  abdomen  is 
undoubtedly  due  to  a  fermentation  in  the  csecum,  and  while  some 
cases  have  been  mistakenly  diagnosed  appendicitis,  it  is  possible 
that  neurasthenia  may  .be  responsible  in  this  way  for  that  disease 
in  a  few  instances. 

Patlwlogy. —Thei-e  has  been  found  by  Hodge  granular  change 


298  TKEATISE   ON   NEEVOUS   DISEASES 

of  the  c3'toplasm  of  the  neurone,  following  induced  exhaustion,  in 
bees.  This  is  accompanied  by  a  diminution  in  size  of  the  cell, 
but  without  actual  degeneration;  the  incipient  pathologic  state 
being  recovered  upon  the  restoration  of  the  bodily  function.  In 
the  human  body  it  is  likely  that  this  same  change  occurs,  which 
has,  however,  not  been  actually  demonstrated  as  yet. 

Adjunct  pathogeneses  of  neurasthenia  are  circulation  of  the 
blood  to  the  cerebral  cortex,  of  toxines,  alloxurie  bodies,  uric  acid,^ 
and  allied  by-products.  The  deficiency  of  excretion  of  solids  by 
the  kidneys  in  a  few  cases  may  be  the  exciting  cause  for  the  de- 
pression of  the  nerve-cell,  and,  therefore,  induction  of  active 
symptoms  of  nerve  exhaustion. 

Diagnosis. — Neurasthenia  is  to  be  told  from  hysteria,  in  the 
latter  of  which  the  emotional  state  of  the  patient  is  the  salient 
point.  In  the  hysterical  person,  too,  there  is  no  muscle  hypotonia, 
as  in  nerve  exhaustion;  perversions  of  common  sensation,  paraly- 
sis, or  convulsions  being  frequent  symptoms  in  hysteria.  The 
inconsistent  s}Tnptomatology  is  a  vital  point  in  determining 
hysteria.  Asthenias  following  prolonged  fevers  are  to  be  distin- 
guished from  neurasthenia  per  se,  since  in  these  symptomatic 
disorders  the  patient  has  not  the  particular  irritable  symptoms 
already  mentioned. 

Secondary  neurasthenia  is  to  be  told  from  primary  or  essen- 
tial neurasthenia  by  finding  a  reflex  source  of  irritation  for  the 
former,  such  as  uterine  diseases,  phimosis,  or  sexual  disorder  in  the 
male  (the  so-called  sexual  neurasthenia).  Neurasthenia  terminalis 
is  the  chronic  form  that  has  become  incurable. 

Prognosis. — The  prognosis  of  acute  neurasthenia  is  good  if 
treated  at  once,  depending  upon  the  non-hereditary  tendency  of 
the  patient.  Cases  with  the  hereditary  taint  are  to  be  given  a 
guarded  prognosis.  Cases  of  secondary  neurasthenia  will  also  re- 
cover promptly  in  proportion  to  the  relief  of  the  primary  exciting 
cause,  such  as  a  proper  repair  of  cervical  and  perineal  tear  with 
prolapsus  uteri;  the  correction  of  errors  of  refraction,  etc. 

The  duration  of  the  average  case  of  simple  neurasthenia  is 
about  three  months.  Chronic  cases  may  last  for  years,  with  re- 
missions of  periods  of  several  months,  or  longer. 

Treatment. — Eevolution  in  the  treatment  of  nervous  exhaus- 

1  See  Laboratory  Studies  on  Uric  Acid  in  Neurasthenia,  etc.,  American 
Journal  of  Insanity,  vol.  Iviii,  No.  1,  1900. 


FUKCTIOlSrAL    NERVOUS    DISEASES  299 

tion  was  made  by  Weir  Mitchell  in  1874,  when  the  difEerent  meth- 
ods employed  in  treating  this  disease  with  more  or  less  success 
were  correlated  and  established  into  guiding  principles.  These 
consist  of  (1)  mental  and  bodily  rest,  (2)  full  feeding,  (3)  isola- 
tion, (4)  massage,  as  well  as  movements,  and  (5)  electricity.  The 
employment  of  this  combination  is  designated  the  "  rest  cure."  It 
should  be  carried  out  for  a  period  of  six  or  eight  weeks  to  three 
months.  If  good  results  are  not  obtained  at  the  end  of  three 
months,  experience  teaches  that  it  is  useless  to  continue  the  treat- 
ment. It  is  essential,  in  carrying  out  the  method,  to  remove  the 
patient  from  home,  or,  if  this  cannot  be,  to  a  remote  portion  of 
the  house,  away  as  far  as  possible  from  the  atmosphere  of  home. 
The  patient  is  kept  absolutely  in  bed  and  given  two  good  nurses,  the 
room  being  kept  at  an  even  temperature,  at  an  average  of  68°  F. 
All  reading  is  to  be  discontinued,  and  even  the  nurses  are  in- 
structed to  converse  but  little  over  pleasantries  of  the  day,  and 
none  as  to  the  patient's  vagarious  complaints.  The  instructions, 
which  should  be  explicitly  written  by  the  physician,  are  further 
as  follows:  Patient  put  on  a  light  milk  diet,  a  glass  being  given 
at  seven  o'clock  in  the  morning,  on  waking,  and  then  every  two 
hours  during  the  day;  thus  from  9  to  10  doses  of  milk  will  be 
given  the  patient  in  twenty-four  hours.  Beginning  at  first 
with  3  ounces,  finally  reaching  8  to  10  ounces,  which  would  make 
27  to  72  ounces  taken  within  the  twentv-four  hours.  At  any 
time  the  patient's  stomach  rebels  the  increasing  dosage  of  milk  is 
held  or  lessened,  or  lime-water  or  peptonization  may  be  employed 
to  assist  digestion.  In  addition  to  this  dietary  the  patient  may 
take  at  7.30  o'clock  in  the  morning  a  cup  of  cocoa,  which  can  be 
repeated  at  eight  o'clock  at  night.  If  there  is  persistent  insomnia, 
and  the  stomach  is  not  being  taxed  for  digestion  too  severely,  a 
piece  of  dry  toast  can  be  given  in  the  evening  with  the  glass  of 
milk  to  vary  the  monotony,  although  it  will  be  found,  in  the  aver- 
age cases  suitable  for  this  treatment,  that  large  quantities  of 
milk  can  be  taken  without  causing  any  disturbance.  The  milk 
diet  is  continued  for  three  or  four  weeks,  and  when  the  patient 
is  gaining  in  weight  the  diet  can  be  increased  to  solids,  such  as 
proteids,  in  the  shape  of  red  meats  and  03^sters,  lamb  chops,  eggs, 
etc.  At  this  stage  it  is  also  well  to  add  a  nutrient,  as  the  fluid 
extract  of  malt,  of  which  there  are  several  varieties  on  the  market, 
the  Johann  Hoff  malt  being  one  of  these. 

As  regards  rest,  the  patient  is  not  even  allowed  ta  sit  up, 


300  TREATISE   OA"   KERVOUS   DISEASES 

except  for  the  moment  of  taking  the  food,  which  should  be  admin- 
istered by  the  nnrse.     ISTor  is  the  patient  permitted  to  read. 

The  patient  should  be  given  a  tepid  sponge  bath,  followed  by 
an  alcohol  rub  in  the  morning,  and  an  alcohol  rub  alone  at  9  p.  m. 

The  braiding  of  the  hair  and  general  toilet  should  be  left  en- 
tirely to  the  nurse.  These  little  details  are  essential  in  the  proper 
carr3'ing  out  of  the  regime,  if  good  results  are  to  be  obtained. 

The  massage  should  be  given  at  about  10  a.  m.,  beginning  at 
first  with  light  effieurage,  finall}'  reaching  the  deep  kneading  of  the 
muscles,  which  is  of  most  value  in  their  nutrition.  This  also  as- 
sists digestion  of  so  large  quantities  of  food.  It  is  interesting  to 
note  the  relation  of  food  supply  to  the  proper  massage  and  Swedish 
movements  in  a  rapidly  progressing  cure  under  the  rest  treatment. 
Electricity  usualh^  is  best  in  the  form  of  faradism,  the  nurse  em- 
ploying it  at  about  three  o'clock  in  the  afternoon,  as  follows :  The 
extremities  are  first  given  the  rapidly  interrupted  current,  then  the 
slow  interrupted  current  is  applied  to  the  muscles  of  the  upper 
extremities,  lower  extremities,  abdomen,  pectoral  region,  erector 
spine,  and  back  group  of  muscles.    (See  Massage  and  Electricity.) 

When  the  patient  has  gained  in  M'eight  and  in  general  nervous 
health  she  is  gradually  got  out  of  bed,  which  should  first  be  by 
sitting  up  in  bed  for  five  minutes  at  a  time,  gradually  increasing 
this  to  twice  a  day,  and  finally  the  patient  is  to  be  lifted  upon  a 
chair.  The  length  of  time  is  increased  until  sitting  up  two  or 
three  hours,  morning  and  evening,  has  been  indulged.  The  patient 
can  move  about  the  room  and  then  get  back  gradually  to  normal 
life — a  renewed  person.  As  a  rule,  improvement  continues  for 
many  weeks  after  the  case  has  been  so  treated. 

The  so-called  partial-rest  treatment  consists  in  having  the  pa- 
tient rest  for  an  hour  or  so  in  midday,  plus  the  hour's  rest  after 
the  massage  in  the  morning,  the  rest  of  the  day  being  devoted 
to  quiet  living,  when  the  patient  may  do  a  certain  measure 
of  work,  if  not  of  a  taxing  nature.  The  diet  in  partial-rest 
cure  is  never  limited  to  milk  alone,  and  malt  is  given  with  the 
meals.  Frequently  the  use  of  phosphorus  in  pill  form,  yts 
of  a  grain  and  a  capsule ;  of  extract  of  chirata,  1  gTain ;  extract  of 
ignatia,  ^  grain,  to  be  given  after  meals,  will  be  of  value.  The 
simple  elixir  of  iron,  quinine,  and  strychnine  is  useful  in  the 
eases  among  the  poorer  classes,  and  reaches  many  of  the  indica- 
tions.^    In  any  case  of  neurasthenia  the  bowels  should  be  kept 

1  See  Appendix. 


FUNCTIONAL    NERVOUS    DISEASES  301 

soluble.  For  this  purpose  the  Lady  Webster  pill  or  the  pill  of 
aloin  (gr.  i),  belladonna  (gr.  tV)j  and  strychnine  (gV)  may  act 
nicely  when  given  at  bedtime.  The  fluid  extract  of  cascara,  in 
from  15-  to  30-drop  doses,  is  a  valuable  remedy  in  these  cases. 
Where  there  is  acidity  of  the  stomach  the  phosphate  of  soda,  in 
dram  .doses,  on  waking,  will  prepare  the  stomach  for  better 
digestion.  In  this  case  the  pill  of  nitrate  of  silver  (gr.  ^),  given 
three  times  a  day,  will  be  of  service  as  a  tonic  to  the  mucous 
membrane  of  the  stomach. 

Hydrotherapeutics  in  neurasthenia  is  very  important,  and 
should  be  used  as  indicated,  by  sponging  in  rest-cure  cases  or  apply- 
ing cold  douche  in  ambulatory  cases.  The  Charcot's  douche  is  one 
of  the  most  valuable  methods  of  applying  water,  and  consists  in 
the  circular  spray  applied  to  the  trunk,  chiefly  over  the  spinal  col- 
umn. In  hydrotherapeutic  procedures  for  neurasthenia  it  is  best 
to  begin  with  a  tepid  sponging  or  a  few  moments'  bath  of  the  body 
accompanied  by  frictions,  and  at  the  end  of  five  or  ten  minutes 
follow  this  up  by  a  cool  spray,  at  a  temperature  of  65°  F.  This 
entire  procedure  is  to  be  followed  by  a  brisk  rub  with  a  Turkish 
towel  and  rest  for  half  an  hour  afterward.  Flushings  of  the  colon 
with  tepid  water  every  other  day  is  valuable  in  those  cases  of  an 
autotoxic  nature.  The  use  of  warm  mud-baths,  such  as  the 
"  fango  "  of  the  Mediterranean,  I  have  seen  do  good  in  cases  ac- 
companied by  the  most  persistent  insomnia.  Where  there  is  an 
irregular  excretion  of  uric  acid,  especially  in  rheumatic  diatheses, 
the  use  of  salicylate  of  soda  will  be  found  of  value  in  relieving  the 
general  irritability  of  the  patient  and  painful  headaches,  probably 
due  to  by-products  circulating  in  the  meninges.  The  correction 
of  the  eyes  should  be  had  in  cases  of  reflex  ocular  defects.  All 
sources  of  irritation  should  be  eradicated,  as  phimosis,  etc.  The 
gynaecologist  is  here  closely  related  to  the  neurologist,  and  while 
too  many  cases  of  neurasthenia  are  assigned  as  gyngecologic,  it 
must  be  stated  that  judicious  study  of  neurasthenia,  following 
childbirth,  will  determine  it  to  be  caused  or  aggravated  by  some 
lesion  of  the  pelvic  tract.  Other  measures  to  be  employed  in 
neurasthenia  are  fresh  air,  sunshine,  and  salt  breezes.  Iron  should 
be  emploj^ed  in  anemic  cases.  Good  food  must  be  had  at  all 
times.  Hypernutrition  is  an  essential  in  the  treatment  of  this 
disease.    The  patient  should  be  encouraged  at  all  times. 

The  climatology  of  neurasthenia  is  not  sufficiently  worked  out 


302 


TPiEATISE   OX   XEETOUS   DISEASES 


at  the  present  time.  It  would  seem  axiomatic  at  all  events  that 
the  patient  should  not  ascend  to  an  altitude  above  2^000  feet. 
A  very  stimulating' climate  should  be  avoided^  as  should  also  dis- 
tricts menaced  by  iogs,  cloudy,  saturated  atmospheres,  with  but 
slight  movements  of  air  currents,  and  the  opposite,  high-wind 
localities.  Sea  level,  with  continuous  heat,  non-varying,  is  bane- 
ful. Thus  the  Bermuda  Islands  and  Florida  are  enervating  local- 
ities. Ideal  conditions  for  the  neurasthenic  patient  include  sea- 
air  in  a  well-wooded  country,  far  enough  from  the  coast  to  avoid 
its  fogs.  Sea  voyage  is,  as  a  rule,  an  excellent  preliminary  to  other 
climatic  measures,  and,  provided  it  is  not  stormy,  will  act  both 
psychicaDy  and  physically  in  soothing  the  nervous  system. 


HYSTERIA 

This  is  a  functional  disease  of  the  nervous  system,  manifested 
by  psychic   (emotional),  motor,  and  sensory  phenomena. 

This  disease  has  been  the  cause  of  much  discussion  as  to  its 
entit}^  and  to  many  other  misunderstandings  in  the  progress  of 
medicine  than  any  other  malady.  It  is  the  old  "  possessions "' 
of  the  middle  ages:  in  common-sense  garb  to-day  a  disease  of 
emotions. 

etiology. — Heredity  is  distinctly  a  cause  of  hysteria.  Xext  in 
order  would  come  moral  shock,  phj'sical  shock,  and  overwork,  and 
sudden  drain  upon  the  system,  as  in  acute  ansemia,  tj^phoid,  etc. 

Symptoms — Psyclio-sensory. — These  are  predominating,  being 
somewhat  masked  in  certain  cases,  and  therefore  misleading  in  the 
differential  diagnosis.  There  are  two  t}^pes  of  hysteria:  the  gen- 
eral state  associated  with  stigmata,  and  the  paroxysmal. 

The  following  table  from  Gowers  illustrates  the  differences 
between  epileptic  and  hysterical  paroxvsms : 


EPILEPSY. 


HYSTERIA. 


Apparent  cause, 
Warning, 

Onset, 

Scream, 

Convulsion, 


None. 

Any,  but  especially  unilat- 
eral or  epicrastric  auras. 

Always  sudden. 

At  onset. 

Ricridity,  followed  by 
jerking,  rarely  rigidity 
alone. 


Emotion. 

Palpitation,  malaise,  chok- 
ing, bilateral  foot  aurae. 

Often  gradual. 

During  course. 

Rigidity,  or  "  struggling," 
throwing  about  of  limbs 
or  head,  arching  of  the 
back. 


FUNCTIONAL    NERVOUS    DISEASES 


303 


EPILEPSY. 

HYSTERIA. 

Biting, 

Tongue, 

Lips,  hands,  other"  people 
or  things. 

Micturition, 

Frequent. 

Never. 

Defecation, 

Occasional. 

Never. 

Talking, 

Never. 

Frequent. 

Duration, 

A  few  minutes. 

More  than  ten  minutes, 
often  longer. 

Restraint  necessary. 

To  prevent  accident. 

To  control  violence. 

Termination, 

Spontaneous. 

Spontaneous  or  induced 
(water,  etc.). 

Among  stigmata  of  hysteria  there  is  the  emotional  element  of 
the  patient,  the  lack  of  control  of  will  power,  which  is  induced  the 
more  by  any  slight  excitement,  particularly  of  a  psA^hic  nature. 
Narrowing  of  the  visual  fields  and  reversal  of  the  colour  fields 
(red  heing  perceived  before  blue)  is  frequently  found  in  hysteria. 
Hysterical  amblyopia  or  hysterical  blindness  is  a  very  rare  symp- 
tom. The  patient  is  able  to  escape  objects  in  walking  about,  but 
has  no  conception  of  their  shape,  size,  or  use.  There  may  be 
photophobia,  achromatopsia,  or  dyschromatopsia. 

Other  psychic  special  sense  symptoms  are  the  following:  Hy- 
perosmia,  anosmia,  and  parosmia;  in  the  ear  we  have  similar  con- 
ditions— deafness,  increased  acuity  of  sense  of  hearing,  tinnitus 
aurium;  the  sense  of  taste  may  be  affected — hypergeusia,  ageusia, 
and  parageusia.    Hysterical  hyperpyrexia  may  occur.' 

The  so-called  h3'sterical  zones  are  frequently  found  on  pressure 
over  the  dorsal,  cervical,  and  lumbar  regions  of  the  spine,  also 
over  the  ovaries  and  beneath  the  breasts — hjsterogenous  zones. 

Other  sensory  disturbances  may  be  geographical  or  segmental 
or  glove-like  areas  of  ansesthesia,  or  a  very  sharply  defined  hemi- 
an^esthesia.  This  is  quite  distinct  from  organic  hemianesthesia, 
where  the  loss  of  sensation  p'asses  beyond  the  median  line — due  to 
interdigitation  of  nerve-fibres  from  each  side  upon  the  skin  be- 
yond the  median  line.    Hysterical  joint  is  a  rigid,  tender  joint. 

The  subjective  sensation  of  tingling  in  the  extremities  (parses- 
thesia)  is  very  usual  in  hysteria.  At  times  this  takes  on  the  hal- 
lucinatory expression  of  ants  creeping  over  the  body,  and  it  is 
very  difficult  to  convince  the  patient  that  this  is  not  so. 

Motor} — The  motor  symptoms  of  the  continuing  state  of  hys- 
teria are,  as  a  rule,  of  excessive  muscular  action,  with  irregular 

1  Hysterical  ataxia  may  occur.     Astasia-abasia  is  inability  to  stand  or  sit 
well  in  hysteria. 


304  TEEATISE   ON   NERVOUS   DISEASES 

and  rapid  movements  of  the  extremities  in  any  particular  voca- 
tion. The  depressive  motor  states  do  exist,  however,  in  the  minor- 
ity of  cases,  where  the  patient  is  apathetic,  inactive,  or  even  seden- 
tary, with  or  without  actual  palsy.  Catalepsy  or  trance  may  per- 
sist for  days.  Palpitation  of  the  heart,  rapid  breathing,  excessive 
or  deficient  secretion  of  urine,  or  even  hsematuria,  may  exist  in 
hysteria.  Dysmenorrhoea  and  amenorrhoea  are  not  uncommon.  I 
have  not  observed  any  particular  alteration  of  the  function  of  the 
bowels  in  hysteria,  although  regurgitation  of  food  or  even  merycis- 
mus  and  extreme  tympanitis  {pliantom  tumor)  are  very  usual. 

The  paroxysmal  stage  of  hysteria  consists  particularly  of  vio- 
lent motor  manifestations,  which,  as  a  whole,  is  described  as  the 
attack  of  hysteria.  In  this  the  patient  will,  after  some  hours  of 
premonition,  of  which  he  will  give  ample  warning,  pass  into  local 
and  general  convulsions,  which  will  assume  the  tonic  type  in  par- 
ticular, the  patient  in  her  contortions  being  drawn  into  opisthot- 
onus or  pleurothotonus.  The  movements  of  the  extremities  are 
more  or  less  vermicular,  rather  than  of  true  clonic  or  tonic  type. 
The  e3^es  are  rolled  about,  although  the  lids  are  generally  kept 
closed,  and  it  will  be  found  that  the  pupils  are  not  dilated,  as  in 
epilepsy.  The  patient  will  not  injure  herself  as  a  rule,  and  falls 
in  the  attack  upon  some  convenient  spot.  While  there  may  be 
frothing  at  the  mouth,  there  is  never  biting  of  the  tongue,  nor  the 
characteristic  cry  seen  in  epilepsy.  The  attack  is  noted  for  its 
dramatic  effect,  and  continues  the  more  when  the  patient  is  in 
special  solicitude  by  her  friends.  An  "  attack  "  of  hysteria  may 
last  from  five  to  ten  minutes  to  several  hours  or  longer,  the 
patient  usually  passing  out  of  the  condition  suddenly,  and  may 
from  sheer  exhaustion  fall  into  sleep  or  a  state  of. trance  lasting 
some  hours.  The  patient  is  not  unconscious  in  the  attack,  and  if 
pricked  with  a  pin  or  otherwise  irritated  will  frequently  resist 
and  give  evidence  of  the  disturbance. 

Certain  passionate  attitudes  are  described  by  the  French  in  the 
"  grand  "  attack ;  these  are  seldom  found  in  America.    They  are : 

1.  Epileptoid. 

2.  Grand  movements. 

3.  Period  of  passionate  attitudes. 

4.  Period  of  delirium. 

The  attack  may  last  twenty  minutes  or  as  many  hours. 
Diagnosis  should  not  be  confounded  with  other  diseases,  ex- 


FUXCTIOXAL    XERVOUS    DISEASES  305 

cepting  possibly  with  neurastlienia,  where  the  emotional  element 
is  wanting ;  but  it  must  be  remembered  that  the  two  diseases  coex- 
ist. Hysterical  manifestations  occurring  as  symptoms  of  brain 
tumour  should  be  borne  in  mind,  and  careful  search  made  in  all 
cases  for  the  symptoms  in  the  latter  disease.  Hysteria  is  very  apt 
to  be  diagnosed  in  some  cases  of  tumour  of  the  frontal  lobe,  .and 
in  this  class  of  cases  the  most  mistakes  are  made. 

Prognosis  is  always  good  as  to  the  paroxysm,  and  to  be  cau- 
tiously given  in  cases  hereditary  in  type.  In  acquired  hysteria, 
where  the  initial  cause  has  been  eradicated  and  impression  has 
not  been  made  too  profound  upon  the  nervous  system,  recovery 
will  frequently  occur  after  proper  treatment. 

Treatment. — This  consists  of  psychic  influence  largely.  Such 
patients  should  be  got  entirely  under  the  control  of  a  physician, 
away  from  sympathetic  friends,  and  firmly,  though  gently, 
treated.  Encouragement  should  be  given  when  the  patient  con- 
trols herself,  thereby  strengthening  the  will  power,  which  is  so 
deficient  in  this  disease.  If  the  system  is  run  down,  a  tonic  line  of 
treatment  must  be  enjoined.  Change  of  scene  is  frequently  neces- 
sary, a  long  sea  voyage  being  desirable  where  there  has  been  a  great 
moral  shock  as  the  exciting  cause. 

Among  drugs  bromides  are  indicated;  asafoetida,  gr.  v,  in  pill 
form;  or  a  compound  sumbul  pill  of  Goodell,  ext.  sumbul,  gr.  j; 
ferri.  sulph.  exsic.  gr.  j ;  asafcetida,  gr.  ij ;  acid,  arsenicum,  gr.  -jV? 
given  thrice  daily.  In  the  attack  the  administration  of  aromatic 
spirits  of  ammonia,  valerian,  or  cold  douches  to  the  face  will  be  of 
value.  Hypodermic  injections  of  plain  water,  or  where  the  con- 
vulsion is  serious  small  doses  of  morf)hine,  guarded  by  atropine, 
will  be  indicated;  or  a  cold  plunge  may  be  given. 

Counter-irritation  to  the  spine,  such  as  by  the  actual  cautery 
or  blisters,  will  frequently  give  prompt  relief  to  the  paroxysm. 

Hypnotism  is  a  valuable  means  for  the  cure  of  certain  classes 
of  cases,  particularly  those  with  local  palsies,  either  motor  or 
sensory.  It  is  of  less  value  in  cases  involving  the  entire  mus- 
culature. Patients  recovering  from  hysteria  should  be  placed 
in  an  entirely  different  surrounding,  if  the  cure  is  to  be  permanent. 
The  care  of  the  hysterical  patient  demands  a  keen  insight  into 
human  nature.  It  is  in  this  disease  that  the  doctor  and  nurse, 
through  judicious  sympathy,  alternating  with  rigidity  of  disci- 
pline, that  the  "paralyzed  will  power''  (for  3uch  is  not  an  inapt 
20 


Fig.  65.— Hysterical  Paralysis.     Braces  and  Wheel-Crutch  applied  to  As- 
sist IN  Walking  till  She  Gained  Power. — Cured. 


FUNCTIONAL    NERVOUS    DISEASES  307 

description  of  the  psychological  state)  greatly  assists  earlier  and 
complete  recovery  of  the  patient.  It  is  essential  in  managing  this 
disease  to  know  the  history,  the  heredity  of  the  affection  or  not, 
and  then  to  learn  the  predisposing  and  exciting  causes  which  have 
led  up  to  the  "  attack,"  be  it  a  passing  syncope,  or  convulsion,  or 
other  form  of  the  acute  malady.  It  is  these  cases  where  especially, 
as  some  author  has  well  said,  the  nurse  should  have  an  eagle's  eye, 
a  lion's  heart,  and  a  lady's  hand  in  dealing  with  the  case,  one  of 
those  optimistic  Greek  maxims  which  gives  vitality  to  all  action. 
In  treating  any  form  of  hysteria,  we  will  find  that  90  per  cent  of 
the  cases  cannot  be  aroused  to  sudden  cures  through  such  agents 
as  hypnotism,  mental  suggestion,  and  the  like;  and  while  such 
measures  should  be  practised  in  selected  cases  by  the  physician 
(with  the  nurse's  aid),  still  a  happy  discretion  in  knowing  when  to 
abandon  these  more  mysterious  methods  of  cure,  successful  as  they 
are  at  times,  is  to  be  impressed  upon  us.  Therefore,  in  treating 
hysteria,  it  should  ever  be'  present  in  mind  that  these  at  times 
quicker  forms  of  treatment  cannot  be  continued  when  we  have 
learned  that  there  has  been  no  rapid  improvement  in  the  symptoms. 
Local  paralysis  or  spasms  of  a  hysterical  nature,  are  in  my  experi- 
ence more  easily  controlled  than  generalized  symptoms,  by  hypnot- 
ism.; so  that  whether  it  be  paralysis,  motor  or  sensory,  or  of  con- 
tractures, the  subconscious  state  is  much  more  difficult  to  influence 
by  this  means.  In  these  cases  the  nurse,  who  is  more  constantly  in 
attendance  than  the  physician,  by  lending  a  spirit  of  hopefulness  in 
pointing  out  to  the  patient  from  day  to  day  improvements  observed 
by  the  physician,  will  re-enforce  therapeutics  greatly.  And  our 
nurses  should  be  better  instructed  in  this  fact  that,  when  the  lowest 
ebb  of  will  power  is  established  over  months  and  years  in  extensive 
chronic  paralytic  forms  of  hysteria,  nerve  energy  occasionally  is 
never  restored ;  and,  therefore,  function  remains  in  abeyance  with- 
out any  pathological  lesion  taking  place  other  than  those  accom- 
panying the  malnutritional  state.  The  greatest  exciting  cause  of 
hysteria  is  some  form  of  fright,  as  is  instanced  in  a  case  under  the 
writer's  care,  which  was  awakened  by  a  rat  running  across  the  bed, 
since  which  time  she  has  had  hysterical  stigmata  with  generalized 
functional  tremor.  Another  instance  is  that  of  a  young  woman  ^ 
who  fell  down  a  flight  of  seven  steps  without  any  serious  bodily 
harm,  although  a  pain  in  the  back  led  her  to  believe  that  she  would 
1  International  Medical  Magazine,  September,  1901.     (See  Fig.  65.) 


308  TKEATISE    OX    NERVOUS   DISEASES 

be  paralyzed,  which  she  finally  was.  She  has  now  been  bedridden 
for  three  years,  with  hysterical  contractures,  ansesthesia  of  the 
lower  limbs  up  to  the  knees,  and  once  a  clonic  hysterical  spasm  of 
the  abdominal  muscles;  which  latter  was  cured  by  producing  the 
initial  stage  of  ether  anaesthesia.  It  took  us  many  months  before 
this  woman  could  be  impressed  enough  to  show  signs  giving 
ground  for  hopeful  prognosis,  and  later  cure.  I  mention  these  rare 
cases  so  that  the  nurses  may  be  taught  to  understand  that  nerv- 
ousness is  not  all  foolishness,  and  has  some  basis  for  its  existence, 
perhaps,  in  the  theory  of  immobility  of  the  neurones;  and  there- 
fore the  diverting  of  the  nerve-currents  irregularly,  which  is  very 
likely  the  fact,  as  suggested  by  Duval  and  Lugaro. 

jSTerve  energy  is,  to  my  mind,  but  the  most  refined  form  of 
electricity.  There  are  some  physiological  phenomena  which  tend 
to  prove  this,  as  in  the  sense  of  light-flash  perceived  when  the 
oculist  severs  the  optic  nerve  in  enucleation,  or  in  the  sudden  res- 
toration of  power  and  sensation  following  nerve  suture,  as  in  a 
case  of  traumatic  operation  of  the  ulnar  nerve  recently  seen  by 
the  writer.  We  have  in  this  theory  a  reason  for  the  efficacy  of 
electricity  in  nervous  diseases. 

TRAUMATIC    HYSTERIA 

Synonyms:  Railway  spine;   Traumatic  'back;   Traumatic  neurasthenia 

Definition  and  Causes. — This  is  a  form  of  hysteria,  the  result 
of  psychic  and  physical  injury.  By  some  it  is  thought  to  be  a  func- 
tional disorder;  by  other  authorities  to  have  an  organic  basis,  the 
milder  eases  not  having,  as  yet,  the  pathology  fully  determined. 
Others  describe  the  condition  as  entirely  mental.  Unfortunate^, 
this  is  a  disease  in  which  the  wildest  variation  of  opinion  exists  as 
to  its  nature.  We  shall  give  what  is  accepted  by  the  best  authori- 
ties. Traumatic  hysteria  is  more  frequent  in  neuropathic  persons, 
is  precipitated  by  some  form  of  physical  injury,  in  contradistinc- 
tion to  the  idiopathic  hysteria,  so  called,  which  usually  has  its 
exciting  cause  in  some  psychic  trauma  alone.  Traumatic  hysteria 
is  more  common  in  the  male  sex,  in  whom  it  is  more  severe,  as  a 
rule,  than  in  the  female  sex.  The  reason  for  the  more  frequent 
occurrence  in  males  is  undoubtedly  due  to  the  liability  to  injury 
in  men. 

Symptoms  and  Divisions. — The  history  of  its  onset  is  usually 


FUNCTIONAL    NERVOUS    DISEASES  309 

as  follows :  The  patient  is  struck  upon  the  back  or  thrown  from  a 
railway  carriage,  being  discovered  in  a  more  or  less  condition  of 
shock,  with  or  without  consciousness ;  and  when  he  is  restored  the 
physical  injiiry  has  impressed  itself  so  upon  him,  that  with  the 
mental  instability  induced,  the  patient  imagines  that  he  is  seri- 
ously injured,  whether  this  be  actually  the  case  or  not.  On  this 
latter  depends  the  dividing  course  in  the  symptomatology.  If  the 
physical  injury  has  been  of  slight  nature  the  neurotic  person  will 
develop  symptoms  entirely  psychical.  Or,  if  an  injury  to  the  mus- 
cles or  ligaments,  which  in  time  is  healed,  occurs,  the  length  of 
time  of  the  actual  trouble  will  be  prolonged  in  such  a  case  by  the 
fixed  hysteria  established  during  the  course  of  the  real  trouble. 

The  second  class  of  cases  develop  actual  disease  of  the  mem- 
branes and  spinal  cord  of  a  subacute  inflammatory  character;  or 
it  may  consist  of  heemorrhage  within  the  cord,  or  to  irritable  weak- 
ness (neurasthenia),  and  finally  to  degeneration. 

The  first  class  of  cases  presents  the  typical  hysterical  symptoms, 
plus  some  local  manifestations,  the  result  or  supposed  result  of  the 
injury.  In  the  first  instance,  of  course,  the  actual  lesion  is  soon 
dissipated;  in  the  second  subdivision,  the  history  of  an  accident 
plus  these  persisting  localizing  phenomena  make  plain  the  organic 
nature  of  the  disease. 

In  the  purely  hysterical  cases  the  patient  usually  complains  of 
rigidity  of  the  back,  which  upon  physical  examination  is  deter- 
mined to  exist  as  the  result  of  tonic  spasm  of  the  erector  spinge 
groups  of  muscles.  Along  the  spine  there  are  points  of  exquisite 
tenderness  apt  to  be  localized  over  cervical,  dorsal,  and  lumbar 
enlargements  of  the  cord.  This  tenderness  upon  superficial  pres- 
sure is  more  than  upon  deep  pressure,  to  which  there  would  be 
exception  only  in  the  cases  where  muscle  or  tendon  injury  still  pre- 
vailed. In  the  latter  case  so-called  '''' tender-spots "  will  remain 
after  the  muscle  is  healed  at  the  site  of  the  original  injury.  The 
patient  becomes  irritable,  tires  at  the  slightest  exertion,  mental 
or  physical.  Palpitation  of  the  heart,  bradycardia  or  tacliycardia, 
may  exist,  and  these  symptoms  frequently  are  not  synchronous  with 
the  pulse-beat.  Per  contra,  the  pulse  may  be  running,  feeble,  and 
irregular,  while  the  cardiac  muscle  is  not  especially  disturbed  in 
function.  This  cardio-vascular  condition  gives  evidences  of  the 
widespread  irritability  of  the  sympathetic  nervous  system,  which 
is  probably  the  more  affected  because  of  the  relation  of  the  gan- 


310  TEEATISE   OX   XEEVOUS   DISEASES 

glia  to  the  spinal  column,  where  concussion  or  a  blow  upon  the 
back  would  transfer  the  physical  effect  immediately  to  these  gan- 
glia Mng  upon  the  bodies  of  the  vertebrs.  Other  vaso-motor 
changes  are  local  or  general  flushing  and  sweating  or  coldness  of 
the  extremities.  Seldom  is  there  a  true  cyanosis,  however.  Other 
organs  affected  largely  through  the  sympathetic  nervous  system 
are  the  stomach,  producing  gastrectasia,  borborygmus,  hj^peracid- 
ity  from  fermentation  of  food,  and  intestines,  causing  alternating 
serous  diarrhoea,  abdominal  cramp,  and  physical  signs  of  pseudo- 
appendicitis.  The  kidney  secretion  may  also  be  affected,  so  that 
anuria,  polyuria,  or  even  dysuria  may  occur.  Irregularity  of  the 
sphincter  muscle  of  the  bladder  may  exist,  inducing  spasm  or  re- 
laxation with  symptoms  of  tenesmus,  incontinence  of  urine,  etc. 

The  knee-jerks  and  other  deep  reflexes  are  greatly  increased, 
but  the  valuable  point  in  diagnosis  of  this  first  division  is  that 
true  ankle  clonus  is  not  present.  The  muscles  are  flabby  and  do 
not  show  reaction  of  degeneration  nor  localized  wasting. 

Seldom  do  sensory  symptoms  occur  other  than  parsesthesia  or 
hyperEesthesia ;  anassthesia,  as  in  simple  hysteria,  never  occurring. 

The  psychic  symptoms  are  sometimes  bizarre,  being  entirely 
of  hysterical  nature,  including  stigmata  and  paroxysms  of  this  dis- 
ease in  quite  exaggerated  form.     (See  Hysteria.) 

The  symptoms  of  the  second  class  of  cases  are  again,  in  the 
majority  of  instances,  largely  of  psychic  nature.  In  addition  there 
are  signs  of  organic  disease. 

The  milder  eases  will  present  the  signs  of  rigidity  of  the  spine, 
already  described,  plus  physical  evidences  of  chronic  injury  to 
the  tissues  around,  between,  or  within  the  spinal  vertebra.  The 
points  of  exquisite  tenderness,  made  worse  by  the  slightest  move- 
ment, and  perhaps  with  some  superficial  swelling,  would  indicate 
a  myositis.  Deeper  lying  points  of  tenderness,  also  exaggerated 
by  slight  movement  of  the  spine,  with  in  some  eases  undue  separa- 
tion of  the  spinous  processes,  would  indicate  relaxation  or  tear 
of  intervertieal  ligaments  or  disks,  in  the  latter  of  which  great  pain 
would  be  experienced,  when  the  patient  should  be  assisted  to  stand 
on  his  toes  and  then  dropped  cautiously  upon  the  heels.  These 
patients  are  never  in  any  degree  of  comfort,  are  usually  harassed 
by  severe  pain,  though  periodic  and  Avorse  at  night,  preventing 
sleep.  Symptoms  induced  from  the  persistent  insomnia  may  end 
in  a  mild  grade  of  mania  or  even  of  delusions  as  to  their  friends, 


FUNCTIONAL    NERVOUS    DISEASES  311 

especially  where  the  doctor  and  relatives  give  out  that  there  is  no 
organic  trouble  present.  The  reflexes  are  greatly  heightened,  the 
musculature  is  frequently  in  hypertonia,  due  to  irritation,  and 
pseudo  ankle  clonus  may  exist.  In  the  severer  cases  in  this  second 
class  the  membranes  of  the  cord  are  congested  or  in  subacute  in- 
flammation, which  may  in  time  extend  to  the  spinal  cord  itself, 
producing  passive  congestion  or  low-grade  myelitis,  which  can  be 
determined  by  the  discovery  of  persistent  ankle  clonus,  involve- 
ment of  the  bladder,  either  incontinence  or  resultant  cystitis,  and 
rectal  incontinence  similar  to  an  ordinary  myelitis.  A  typical  case 
of  this  sort  the  writer  has  recently  seen  where  hysteria  has  been 
pronounced,  and  yet  where,  in  spite  of  a  large  recovery  in  a  suit 
for  damages,  the  patient  still  has  the  evidence  of  organic  disease 
referred  to. 

Diagnosis. — Simple  hysteria  is  distinguished  by  the  absence  pf 
a  back  injury.  Malingering  is  told  by  the  fact  that  the  malingerer 
cannot  consistently  simulate  the  symptoms  constantly. 

Prognosis. — The  duration  of  traumatic  hysteria  is  very  indefi- 
nite, the  hysterical  cases  at  times  being  almost  as  persistent  and 
chronic  as  in  organic  change  of  the  cord.  Where  organic  lesions 
exist  we  cannot  hope  for  entire  recovery.  The  pure  case  of  hysteria 
may  be  well  in  a  few  months.  That  large  class  of  chronic  com- 
plainers  are  incurable  hysterics  or  are  the  organic  cases. 

Prognosis  depends  entirely  upon  the  skill  of  diagnosis  in  distin- 
guishing the  different  forms  mentioned,  and  in  our  ability  to  com- 
mand proper  moral  and  physical  treatment  of  the  respective  forms. 
It  is  always  most  guarded,  but  it  is  probable  that  the  patient 
in  this  disease  more  than  in  any  other  may  recover  promptly. 

Pathology. — This  will  vary  from  nothing  (the  first  division) 
to  (in  the  second  class  of  cases)  inflammation  of  muscles,  liga- 
ments, or  tendons,  or  tearing  of  fibres  of  the  same  structures. 
Periostitis,  chronic  congestion  or  inflammation  of  the  meninges, 
and  the  final  passive  congestion,  or  degeneration  of  the  neurones 
in  the  spinal  cord,  or  haemorrhage  within  the  cord  may  represent 
the  pathological  findings  in  the  most  serious  cases. 

Treatment  of  traumatic  hysteria  consists  in  rest  cure  for  sev- 
eral months  in  the  moderate  grade,  without  organic  lesion,  or  of 
psycho-therapeusis  in  the  most  available  forms,  including  .hyp- 
notism in  these  entirely  functional  cases.  The  rest  treatment  is,  of 
course,  absolutely  essential  where  any  organic  condition  either  af 


312  TEEATISE   OX   XEETOUS   DISEASES 

nervous  system  or  surroimding  tissue  exists.  It  may  be  necessary 
in  some  cases,  in  addition,  to  procure  fixation  of  the  spine  by 
the  aid  of  plaster-jacket  or  body  brace,  or  by  means  of  head  exten- 
sion with  the  jury-mast.  This  is  to  be  prolonged  until  the  parts 
have  healed  or-  are  greatly  relieved.  Counter-irritation  over  the 
spine  by  means  of  strong  tincture  of  iodine,  continued  over  several 
weeks,  the  use  of  blister  or  of  actual  cautery  may  be  of  great  value. 
It  must  not  be  forgotten  that  possibly  chipping  off  of  a  part  of 
a  lamina  or  a  vertebral  disk  may  occur,  which  must  be  searched 
for  by  means  of  X-rays  in  all  cases,  and  if  found,  surgical  pro- 
cedure should  be  resorted  to.  These  patients  ought  never  be  given 
morphine,  else  we  establish  another  neurosis,  and  if  drugs  are  to 
be  used,  they  should  be  administered  sparingly,  the  indication 
being  to  quiet  the  central  nervous  system,  in  which  the  bromides, 
small  doses  of  chloral,  hyoscine,  and  belladonna  may  be  of  great 
service.  In  the  functional  cases  also  change  of  scene  is  important, 
and  in  any  cases  where  damage  suits  are  pending  they  should  be 
got  rid  of  at  the  earliest  moment,  the  phj'sician's  duty  being  simply 
to  give  advice  from  a  purely  medical  standpoint,  or  upon  the  wit- 
ness stand  to  state  his  knowledge  of  the  form  and  severity  of  the 
disease  from  which  the  patient  is  then  suffering.  Much  of  the  dis- 
credit upon  the  profession  will  be  dissipated  when  physicians  learn 
to  give  their  own  opinions  after  sufficient  study  in  order  to  know 
what  are  the  underlying  conditions  in  this  unfortunate  class  of 
cases. 

SALTATORY  SPASM 

Saltatory  spasm  is  so-called  jumpers  disease,  a  hysterical  dis- 
order occurring  in  epidemics  in  Maine  and  Canada.  It  is  known  as 
mlryachit  in  Eussia,  and  in  Java  as  lataJi.  When  the  patient 
attempts  to  stand  there  are  strong  contractions  of  the  leg  muscles 
which  cause  a  jumping  or  springing  motion. 

SALAAM    CONVULSIONS 

This  is  a  hysterical  manifestation  occurring  in  certain  nation- 
alities, particularly  the  Malay  race.  The  patient  usually  is  in  a 
morbid  condition  of  mind,  and  without  known  cause  will  develop 
peculiar  convulsive  seizures,  from  which  he  is  violently  thrown  to 
the  ground  in  a  prone  position.  This  will  continue  for  some  min- 
utes, or  even  hours,  the  patient  finally  becoming  exhausted  and 
passing  into  a  rigid  contraction  of  the  general  musculature. 


FUNCTIONAL    NEKVOUS    DISEASES  313 

WRITER'S  CRAMP 

Synonyms:  Artisan's  palsy ;  Ironer's  cramp;  Occupation  neurosis 

The  above  are  names  given  to  allied  conditions,  usually  of  a 
localized  nature,  affecting  the  muscles  of  a  part  in  spasmodic  con- 
tractions, associated  with  more  or  less  pain  along  the  nerve-trunks, 
and  frequently  accompanied  by  wasting  of  the  muscles  involved. 
There  are  several  types  of  the  disease,  depending  upon  the  physique 
of  the  person  affected  and  upon  the  nature  of  the  occupation,  as 
above  indicated. 

Causes. — The  condition  is  fundamentally  a  form  of  nerve  ex- 
haustion, and  is  probably  central  in  the  majority  of  cases,  the 
neurones  controlling  particular  movements  being  exhausted  as  in 
neurasthenia.  The  main  predisposing  cause  is  heredity  as  to  neu- 
roses, and  secondarily,  confinement  and  overwork,  such  as  the 
constant  application  and  overwork  of  a  group  of  muscles,  especially 
when  in  a  constant  cramped  position.  To  this  primal  pathogenesis 
must  be  added  the  irritation  produced  by  the  variety  of  metabolites 
formed  in  excess  or  improperly  eliminated.  Leucomaines  may  be 
complicating  factors.  Some  cases  seem  to  be  almost  entirely  local 
in  nature.  These  are  the  cases  in  which  the  central  nervous  sys- 
tem is  not  called  upon  for  a  proportional  expenditure. 

The  more  localized  types  of  occupation  neuroses  may  be  divided 
into  muscular,  neuriUc  (neuritis  or  not),  and  arterial,  depending 
upon  duration  and  anatomical  structures  most  injured.  There  are 
no  absolutely  fast  dividing  lines  between  these  latter  forms. 

Muscular  Cases. — This  comes  on  from  sudden  rather  violent 
overuse  of  muscles,  as  in  cases  of  brakemen  or  motormen.  A  sub- 
acute myositis  is  very  likely  set  up  in  these  cases.  They  are  usually 
of  shorter  duration  than  the  other  forms,  and  abate  with  the 
removal  of  the  cause — i.  e.,  with  rest  of  the  affected  muscles. 

Neuritic  Cases. — Here  we  have  a  peripheral  neurosis,  which 
may  pass  on  to  a  subacute  peripheral  neuritis.  This  class  is  mani- 
festly more  severe  than  the  other  forms.  Symptoms  consist  of 
tenderness  along  nerve-trunks,  accompanied  by  spasm  of  the  mus- 
cles when  attempting  to  use  them,  especially  in  the  occupation 
■which  developed  the  neurosis.  Pressure  along  the  nerve-trunks,  as 
is  seen  in  telegraphers,  who  rest  their  elbows  on  the  desk,  will 
aggravate  the  condition.  A  continuing  numbness  of  the  affected 
part  is  another  prominent  symptom. 


314  TEEATISE   ON   NERVOUS   DISEASES 

Vascular  Cases. — That  these  should  be  given  as  a  type  per  se 
may  be  considered  dubious  from  a  neurological  standpoint,  but 
undoubtedly  the  arterio-capillary  involvement  is  the  primogene- 
sis  of  a  number  of  cases,  and  the  classification  seems  at  least 
to  be  warranted  clinically.  In  these  cases  the  nervi  vasori  and 
vaso-motor  nerves  are  irritated.  In  such  cases  there  are  none  of 
the  cardinal  symptoms  of  the  ordinary  cases  of  writer's  cramp,  no 
severe  spasm  or  paresis  of  muscles,  but  paresthesia  of  fingers  and 
forearms.  Finally,  along  with  delayed  sensations  of  all  forms 
(but  little  tenderness),  there  is  particularly  a  clamminess  of  the 
parts  so  affected.  These  cases  are  distinguished  from  acroparges- 
thesia  by  the  fact  that  there  is  evident  pressure  cause  for  the 
peripheral  irritation  and  from  the  fact  that  marked  arterial  scle- 
rosis is  found  wanting.  The  arterial  cases  may  also  be  divided 
into  the  neurasthenic  and  non-neurasthenic. 

The  muscular  class  of  cases  are  the  more  frequent,  and  from 
the  fact  that  the  muscles  are  more  affected;  and  in  which  treat- 
ment is  the  more  prompt  in  producing  results.  The  prognosis, 
therefore,  is  much  better  in  this  class  of  artisan's  palsy. 

The  neuritic  class  are  the  usual  cases  described  in  classical  arti- 
cles on  the  subject,  and  are  the  most  persistent  ones,  in  which  there 
is  almost  constantly  a  background  of  neurasthenia  complicating. 
Such  patients  are  usually  emaciated  and  suffer  from  insomnia  and 
anorexia.    Morris  Lewis  has  best  described  this  disease.^ 

Prognosis. — In  the  vascular  cases  this  is  good  in  the  absence  of 
neurasthenia ;  and  the  patient  will  recover,  as  a  rule,  with  the  gen- 
eral upbuilding  of  health  after  the  occupation  has  been  abandoned. 
In  a  study  of  some  50  cases  of  artisan's  palsy,  at  the  Infirmary 
for  Nervous  Diseases,  occurring  over  some  twenty-five  years,  the 
writer  made  a  study  of  the  Remote  Results  of  Artisan's  Palsy  ^ 
with  the  following  conclusions:  That  with  the  proper  kind  of 
treatment,  and  if  persisted  in,  these  cases  ofEer  a  better  recovery 
than  was  formerly  supposed.  Two  to  five  years  seems  to  be  a 
fair  time  for  cure  in  the  average  ease  of  neuritic  type.  Where 
the  central  nervous  system  is  involved  we  have  the  terminal  stage 
of  irritation  (neurasthenia),  most  unpromising  for  complete  cure. 
Muscular  types  offer  the  most  favourable  prospect  for  ameliora- 

1  The  Neurologic  Disorders  of  Writers  and  Artisans.  Pepper's  System  of 
Medicine,  vol.  v,  pp.  504-542. 

^  University  of  Peima.  Medical  Magazine,  May,  1897. 


FUNCTIONAL    NEEVOUS    DISEASES  315 

tion;  here  no  remote  conditions  need  be  entertained,  and  stop- 
ping the  progress  of  the  disease  will  generally  produce  rapid 
recovery.  The  hybrid  cases  I  have  designated  arterial  type  are 
also  very  persisting.  In  proportion  as  arterial  sclerosis  is  absent 
and  external  irritation  is  prominent  will  the  hope  for  complete 
recovery  be  gratified  within  six  months  to  a  year  under  the  proper 
kind  of  treatment.  Where  the  disease  lasts  beyond  a  year,  the 
remote  efl^ects  are  arterial  sclerosis,  probably  induced  by  the  vaso- 
motor irritation  of  such  long  duration;  then  the  deposit  of  lime 
salts  will  of  course  continue  with  some  remissions,  as  is  the  his- 
tory of  this  form  of  arterial  degeneration. 

Treatment. — The  use  of  antirheumatics,  such  as  potassium 
iodide,  the  lithic  salts,  and  sodium  salicylate,  are  of  great  advan- 
tage in  those  cases  where  rheumatic  diatheses  prevail.  The  use 
of  nitroglycerin  or  ergot  will  be  of  value  in  the  arterial  cases  with 
constriction  or  relaxation  respectively  through  action  upon  the 
vaso-motor  nerves.  Nutrient  drugs  such  as  cod-liver  oil  and 
the  hypophosphites  Mdll  be  of  help  in  cases  associated  with  mal- 
nutrition. Fresh  air  and  sunlight  should  be  insisted  upon  in  all 
cases,  also  relaxation  from  overwork.  We  should  employ  hgematics, 
such  as  Bland's  pills,  in  cases  of  anaemia.  Since  the  psychology  of 
the  disease  is  to  produce  a  peculiar  morbid  depression,  it  is  impor- 
tant for  the  physician  to  gain  the  confidence  of  the  patient  and 
stimulate  him  'to  the  thorough  realization  of  the  need  of  careful 
treatment.  The  local  measures  of  value,  which  should  be  contin- 
ued for  many  months,  are  massage,  galvanism,  and  hot  local  bath- 
ing to  the  part  from  three  to  five  minutes  daily,  in  cases  where 
there  is  considerable  pain  or  spasm.  In  some  cases  a  splint  should 
be  applied  to  the  affected  m^ember  in  order  to  afford  relief  of 
spasm  by  enforced  rest.  Treatment  of  existent  neurasthenia  is 
absolutely  essential  for  success. 


CHAPTER   XYil 


VASO-MOTOR  AND   TROPHIC  DISORDERS 

Synonyms:  Parry's  disease  (1825);  Graves's  disease  (1835);  Basedow'' s 
disease  (1840),  etc. 

EXOPHTHALMIC   GOITRE 

This  is  a  disease  characterized  by  rapid  heart,  exophthalmos, 
enlargement  of  the  thyreoid  gland,  and  by  disturbance  of  the 
vascular  system  through  functional   disease   of  the   sympathetic 

nervous  system. 

Causes. — There  are  vari- 
ious  theories  for  this  affection. 
That  it  is  a  functional  disease- 
of  the  sympathetic  nervous 
system  is  held  by  most  author- 
ities. Exciting  causes  are 
overwork,  fright,  auto-intoxi- 
cation, or  infection.  It  is 
closely  allied  to  simple  goitre, 
or  at  least  hj^brid  cases  fre- 
quently are  found.  Whether 
or  not  disturbance  of  the  thyr- 
eoid function  has  primarily 
to  do  with  Graves's  disease  is 
still  debatable. 

Those  contending  for  this 

consider     that     there   .  is     an 

excess    of    secretion     (hyper- 

thyrea),   as   against   the   lack 

of  that  secretion  as  a  cause  of 

the    development    of    myxoe- 

dema  (athyrea).     The  age  of 

onset  is  usually  between  the  twentieth  and  thirtieth  years,  and  it 

is  sometimes  seen  in  several  of  a  family.     Some  observers  consider 

that  the  affection  is  due  to  a  lesion  in  the  oblongata. 

316 


i''lG. 


66. — Exophthalmic  Goitke.    Pkom- 
INENT  Eyes  and  Thyreoid  Gland. 
(Howard  Hospital.) 


VASO-MOTOR    AXD    TROPHIC    DISORDERS       317 

Syni.ptoins. — There  are  two  types  of  this  disease,  namely,  the 
acute  and  the  chronic.  The  former  type  may  develop  with  great 
rapidity,  following  an  attack  of  vomiting  and  diarrhoea,  tachy- 
cardia, and  throbbing  of  the  arteries.  Such  cases  may  die  in  the 
attack  as  early  as  the  third  day  of  the  affection.  Marked  cerebral 
symptoms  may  be  present  in  this  form.  More  frequently  the  grad- 
ual onset  prevails,  the  three  cardinal  symptoms  varying  in  order  of 
onset.  The  cardiac  and  vascular  symptoms  are  usually  first  to 
develop,  the  patient  complaining  of  palpitation  and  dyspnoea.  The 
pulse  is  found  to  be  increased  in  force,  the  apex  beat  is  in  the  nor- 
mal position,  and  the  carotids  and  abdominal  vessels  may  be  throb- 
bing visibly.  Occasionally  capillary  and  venous  pulsation  may  be 
seen  in  the  hands.  At  its  height  the  piilse  rate  may  be  from  140 
to  160,  or  even  more  in  some  cases.  It  seldom  drops  below  95 
per  minute.  Emotion  tends  to  increase  the  heart  action,  and  on 
exposure  of  the  skin  on  the  chest  a  transient  hypersemia  quite  fre- 
quently can  be  seen.  Basic  murmurs  are  not  unusual.  Long- 
standing cases  may  present  cardiac  hypertrophy.  The  heart 
sounds  become  greatly  accentuated,  some  cases  having  been  record- 
ed where  the  heart-beat  could  be  heard  several  feet  away  from  the 
patient.  Usually  exophthalmos  follows  next,  and  is  readily  recog- 
nised by  protrusion  of  the  eyeballs,  and  also  by  the  lids  not  com- 
pletely covering  the  sclerotic  coat.  The  protrusion  may  sometimes 
cause  semi-dislocation  of  the  eyeballs.  Vision  usually  remains  in 
a  normal  state.  Von  Graefe's  sign,  consisting  of  the  inability  of 
the  particular  lid  to  follow  the  downward  movement  of  the  eye- 
ball, though  striking,  is  not  a  frequent  symptom.  Stellwag's 
sign  consists  in  a  greater  width  of  the  palpebral  aperture  than  in 
health  owing  to  the  retraction  of  the  lid,  this  usually  being  found. 
The  patient  winks  infrequently.  Occasionally  there  is  lack  of 
convergence  of  both  eyes.  The  optic  nerves  are  seldom  affected, 
but  pulsation  of  the  retinal  arteries  is  common.  The  thyreoid 
swelling  usually  appears  with  the  exophthalmos.  It  is  generally 
symmetrical,  but  seldom  as  large  as  in  ordinary  goitre.  The  blood- 
vessels are  much  dilated,  and  the  gland  is  occasionally  seen  to 
pulsate ;  in  either  instance  a  thrill  may  be  felt,  or  on  auscultation 
we  discover  a  bruit  or  even  a  loud  systolic  murmur.  Motor  symp- 
toms consist  of  fine  general  tremors.  The  patient  becomes  ansemic 
and  emaciated.  He  may  be  slightly  feverish  at  times.  Vomiting 
or  diarrhoea  may  exist  and  are  usually  paroxysmal  in  occurrence. 


318  TREATISE   OX   XERYOUS   DISEASES 

Great  comjilaiiit  generally  is  made  of  throbbing  sensations  in 
the  heacl^  accompanied  by  a  sense  of  flushing  and  heat  Avith  profuse 
perspiration.  The  skin  will  be  found,  when  carefully  examined, 
to  be  pigmented,  favouring  Addison's  disease ;  or  patches  of  leuco- 
derma,  or  atrophy  of  pigment  and  urticaria  may  exist,  as  may 
also  areas  of  solid  oedema.  Myxoedema  has  been  found  to  coexist 
with  this  affection.  The  patient  is  also  of  irritable  temperament 
and  of  changeful  disposition,  mental  depression  very  frec[uently 
occurring.  Acute  mania  ma}"  develop.  A  sense  of  giving  Avay  of 
the  legs,  a  muscular  weakness,  may  exist.  There  is  great  diminu- 
tion in  the  electrical  resistance,  which  may  be  due  to  moisture  of 
the  skin  from  vaso-motor  dilatation.  Bryson  has  noticed  that  the 
chest  expansion  is  greatly  diminished.  Breathing  is  hurried  and 
shallow.  Albuminuria  and  glycosuria  are  not  usual  symptoms 
found  present  upon  frequently  examining  the  urine.  Polyuria, 
hyperidrosis,  and  cedema  are  usual.  Subnormal  temperature 
might  occur. 

Prognosis. — This  disease  usually  lasts  for  many  years,  but  after 
six  months'  time  it  may  disappear.  Complete  recovery  is,  as  a  rule, 
very  rare.  Instances  are  recorded  of  the  acute  form  recovering 
within  the  same  period  of  time  as  its  development — a  few  days. 

Pathology. — This  is  inconstant.  The  heart  is  often  dilated. 
Fatty  change  of  its  walls  may  be  present.  The  lobes  of  the 
thyreoid  are  large,  firm,  and  pulpy.  Colloid  degeneration  and  cyst 
formation  may  be  found.  The  vessels  are  thickened  and  athe- 
romatous. There  is  proliferation  of  connective  tissue  through- 
out the  gland.  In  the  bulb  and  cord  haemorrhages  have  been 
found. 

Treatment. — This  consists  in  rest,  the  absence  of  worry, 
abundance  of  sunlight  and  oxygen ;  the  use  of  galvanism,  placing 
the  positive  pole  over  the  apex  of  the  heart  and  a  Y-shaped  divi- 
sion of  the  negative  pole  upon  each  side  of  the  neck  over  the  cervi- 
cal sympathetic,  with  from  3  to  10  milliamperes,  once  or  twice 
weekly,  has  proved  of  value  in  our  hands  to  lessen  the  rapidity 
of  the  heart.  The  use  of  strophanthus  in  continuous  dosage  is  of 
advantage  for  the  cardiac  irritability;  where  there  is  great  vaso- 
motor disturbance  prominent,  the  use  of  digitalis  or  its  products, 
especially  digitaline  (^  grain  t.  i.  d.),  will  prove  of  value.  The 
alterative  and  hsematinic  effect  of  arsenic,  especially  when  com- 
bined with  iron,  will  prove  a  boon  in  anaemic  cases.     Ergot  is 


VASO7MOTOR    AXD    TROPHIC    DISORDERS        319 

recomineiiclcd  by  some  writers.  Tincture  of  belkidonn;!  will  very 
frequently  give  relief,  and  should  be  pushed  to  the  physiological 
limit.  Resort  to  the  rest-cure  may  be  a  necessity  in  the  worst  of 
cases.  The  application  of  Letter's  tube,  or  an  ice-bag  over  the 
heart  or  lower  part  of  the  neck,  frequently  gives  relief.  Organo- 
therapy has  not  been  successful  in  the  majority  of  cases.  Surgical 
treatment  cannot  be  recommended,  although  several  recoveries 
have  already  been  reported  after  excision  of  the  cervical  sympa- 
thetic or  part  of  the  gland  itself. 


GLASS-BLOWER'S    DISEASE 

This  is  a  vaso-motor  neurosis,  due  primarily  to  sudden  increase 
of  blood  pressure  and  the  forcing  into  the  blood  an  excess  of 
oxygen  caused  by  the  patient  blowing  into  the  blow-pipe,  fol- 
lowed by  a  deep  inspiration  when  the  mouth  is  removed,  at  which 
time  the  blood  becomes  overaerated;  the  latter  being  the  real  cause 
of  the  cardinal  symptoms  of  the  disease.  The  former  is  productive 
of  emphysema  of  the  lungs,  which,  therefore,  is  a  common  com- 
plication. Dizziness  is  a  marked  symptom,  and  is  an  exaggeration 
of  what  can  be  produced  by  respirations  deeply  and  rapidly  taken 
during  health.  In  these  patients  there  is  a  beginning  hypertrophy 
of  the  right  ventricle,  accentuation  of  the  second  aortic  sound, 
and  an  increased  pulse  volume  and  rate.  There  soon  results  ex- 
haustion, dyspnoea,  and  a  rapid  running  pulse,  the  patient  com- 
plaining of  fulness  of  the  head,  and  while  exhilarated  is  unable 
to  co-ordinate  properly.  This  is  due  to  overstimulation  of  the 
central  nervous  system.    Mental  anxiety  is  pronounced. 

Pathology. — This  is,  as  indicated,  overoxygenation  of  the  blood 
primarily,  with  sequent  hypertrophy  of  the  heart  and  vascular  dis- 
ease in  chronic  cases. 

Prognosis. — When  once  firmly  established  the  prognosis  is  ab- 
solutely bad  if  the  patient  continues  the  occupation.  These  cases 
very  seldom  live  after  fifty-five  years  if  they  continue  work  at  the 
same  trade.  If  the  occupation  is  stopped,  it  may  be  that  the 
patient  may  live  quietly  in  comparative  comfort  for  some  years. 

Treatment. — The  patient  should  quit  glass-blowing.  Employ 
antispasmodics,  such  as  lobelia,  where  the  emphysematous  s^^mp- 
toms  are  predominant ;  nitroglycerin  to  steady  the  circulation 
and  overcome  dilatation  of  the  peripheral  vessels.     It  must  be  re- 


320  TEEATISE    OX    XEEYOUS   DISEASES 

membered  that  there  is  a  possibility  of  cerebral  haemorrhage  in 
cases  with  arterial  sclerosis.  Here  the  treatment  is  directed  to  apo- 
plexy.    These  complicated  cases  are  generally  fatal. 

SUDDEN    CHANGES    IN    HAIR 

This  rare  trophic  condition  occurs,  as  a  rule,  as-  the  result  of 
grave  mental  crises  in  life  or  extreme  fright. 

Symptoms. — The  patient  after  severe  psychic  shock,  as  indi- 
cated, may  notice  within  a  few  hours  to  several  days  a  sudden  gray- 
ing of  the  hair  in  streaks  or  in  entirety  in  a  given  area ;  usually  of 
the  scalp  and  eyebrows.  In  some  cases  an  alopecia  will  precede, 
accompanied  by  erythema  or  with  distinct  dermatitis  in  the  area 


Pig.   67.  —  Tkophoxeurosis   of   the   Hair,    showing    Change   from   Dark   to 
White.     (Author's  reported  case.)  ' 

affected;  and  when  the  hair  returns  the  absence  of  colour  will  be 
noted.  The  hair,  as  a  rule,  remains  without  colour  (gray  or 
white) ,  and  may  be  disposed  to  fall  out  from  time  to  time,  depend- 
ing upon  the  mental  condition  of  the  patient  as  well  as  the  nutri- 
tion of  the  body.  The  hair  change  may  result  in  universal  and 
permanent  alopecia"  alone  (Fig.  68). 

Causes. — The  writer  has  records  of  two  cases  produced  by 
shock,  one  in  a  male,  communicated  personally  by  Dr.  E.  Pearce, 
of  Ohio.  Here  the  hair  turned  permanently  gray  in  one  night,  the 
man  having  been  frightened  during  the  civil  war  by  rapidly  fired 

*  American  Medicine,  Dec.  28,  1901. 


YASO-]^IOTOE    AND    TROPHIC    DISORDERS       321 


cannon.  AnotliLT  case  un- 
der our  care  is  of  a  young 
woman,  following  a  dis- 
appointment in  love,  the 
hair  having  dropped  out 
and  then  shortly  regrew, 
being  perfectly  white  (Fig. 
67).  Psychic  trauma  is 
the  cause. 

Pathology. — This  is  in 
an  indefinite  state,  consist- 
ing in  the  absence  of  de- 
posits of  colour  matter, 
which  must  be  dependent 
upon  some  trophic  disturb- 
ance of  the  nervous  sys- 
tem similar  to  other  dys- 
trophies. Metchnikoff  has 
described  the  amoeboid  ac- 
tion of  certain  leucocytes 
which  he  designates  pig- 
mentophytes. 

Prognosis.  —  This  is 
good  so  far  as  the  health 
of  the  patient  is  con- 
cerned. The  hair  seldom 
returns  to  its  normal  col- 
our again. 

Treatment. — Rest  and 
tonics  are  essential.  Drugs 
to  stimulate  the  sweat- 
glands  and  to  favour  the 
deposits  of  normal  colour- 
ing matter  would  be  indi- 
cated, such  as  pilocarpine 
and  iron.  The  static 
breeze  *as  a  stimulant  to 
the  surface  of  the  skin  is 
indicated.  The  use  of 
phosphorus  and  strych- 
21 


^^^^^^^^^H  ''^ 

:^^^^^^^^^B 

Ml 

ii 

^B    ■■ 

\m 

■  lt\ 

il 

W{ 

p^^,^H 

la 

■J 

r^^^^^^^^^^^^^^H 

^^^^^r      ^l^^^l 

^mt      ^j^^^^^^^^^^B 

BlH 

^^^H 

Fig.  fi8.— Universal  Alopecia  of  Nervous 
Origin.     (Philadelphia  Hospital.) 


322 


TREATISE   ON   NERVOUS   DISEASES 


nine ;  or  the  nuclein  bodies^  or  organo-therapy,  as  thyreoid  extract, 
may  prove  of  service  in  the  treatment  of  this  uncommon  aifection. 

HYPEROSTOSIS    CRANII    (CEPHALOMEGALY) 

This  disease  is  allied  to  osteitis  deformans,  originally  described 
by  Sir  James  Paget,  of  London,  in  a  report  of  the  first  case, 
November  24,  1876.     When  the  disease  is  limited  to  the  cranial 


Fig.  69. — Hyperostosis  Cra^jii.     (Author's  reported  case.)  ' 

bones  largely,  as  in  the  case  shown  in  the  two  photographs,  it  is,  as 
already  designated,  hyperostosis  cranii ;  and  becomes  a  neurological 
affection  only  in  its  relation  by  contiguity  of  the  enlarged  bones 
to  the  brain  mass. 

This  affection  is  a  trophic  disturbance,  involving  the  bones  of 
the  skull,  the  rest  of  the  bones  of  the  skeleton  being  but  little 

^  Transactions  of  the  Pathological  Society  of  Philadelphia,  vol.  xviii,  1897. 


VASO-MOTOR    AXD    TROPHIC    DISORDERS       323 

or  uot  at  all  involved.  There  are  two  types  ^  of  cranial  enlarge- 
ments : 

(a)  Upper-head  type. 

(6)  Lower-head  type,  where  the  malar  bones  become  involved 
and  produce  the  leonic  appearance.  The  face  and  head  present  an 
oval  with  the  base  up.     The  bony  overgrowth  may  begin  as  early 


Fig.  70. — Skull-cap  from  same  case  of  HrPEROSTOsis  Ckanii.     (See  Fig.  69.) 


as  the  twelfth  year,  and  usually  it  is  not  later  in  onset  than  the 
twentieth  year.  The  condition  is  undoubtedly  a  bony  dystrophy. 
Symptoms. — The  symptoms  of  this  disease  are  very  indefinite. 
There  is  usually  mental  apathy,  a  state  of  mental  hebetude,  and 
occasionally  a  condition  of  what  we  might  call  "queer."     The 

*  J.  J.  Putnam,  Trans.  Am.  Neurological  Society,  June,  1895. 


324  TEEATISE    OX    XEEYOUS    DISEASES 

patient  may  also  suffer  from  a  dull  headache.  The  hony  enlarge- 
ment is  gradual,  the  hearing  becomes  affected  in  some  cases,  and 
the  hairs  are  noticed  to  become  coarse,  and  even  may  fall  out  to 
some  extent.  The  ease  may  die  of  asthenia  after  many  years,  or 
he  may  be  carried  off  by  some  intercurrent  malad}',  such  as  pneu- 
monia, or  chronic  interstitial  nephritis. 

Pathology. — This  consists  of  a  slow  ostitis.  The  chronic  in- 
flammation shows  under  the  microscope  irregularly  enlarged  Ha- 
versian systeihs,  atrojohy  of  bone  cells,  loss  of  osteophytes  and 
osteoclasts,  and  the  conversion  of  parts  of  bone  into  mere  fibrous 
tissue.  On  the  surface  of  the  bone  there  is,  as  a  rule,  a  condensing 
ostitis.  There  is  frequently  cerebral  arterial  sclerosis  in  marked 
degree. 

Diagnosis. — This  lies  between  the  disease  in  question  and 
spurious  forms  of  hydrocephalus;  but  the  lack  of  exophthalmos 
after  prolonged  cephalic  enlargement  with  other  signs  of  bone 
thickness  would  militate  against  the  latter.  The  case  reported  by 
the  writer  (Figs.  69  and  70)  occurred  in  a  woman  seventy- two 
years  of  age.  Here  the  skull-cap  proved  to  be  1^  inch  in  thickness, 
and  as  far  as  I  can  determine  is  probably  the  thickest  on  record. 

Treatment. — The  treatment  of  this  condition  is,  of  course, 
in  cognito.  Xutritional  measures  and  probable  benefit  from 
organo-therapy  should  be  thought  of.  Antisyphilitic  drugs  should 
be  tried  in  all  cases. 

ADIPOSIS    DOLOROSA 

This  is  described  by  Dercum  as  a  disease  of  adults  in  which 
there  is  a  deposition  of  fat  in  various  parts  of  the  body  seen  in 
the  form  of  bunches  or  nodules,  becoming  uneireumscribed  after- 
ward, and  accompanied  by  pain,  diminished  sensibility,  and  great 
muscular  weakness.  There  is  the  sensation  as  of  a  bunch  of  worms 
transmitted  to  the  hand  on  palpation.  Some  15  or. more  cases  have 
been  reported  by  Dercum,  Henry  Ewald,  Peterson,  Loveland, 
Spliler,  Eshner  et  al. 

Diagnosis. — This  condition  must  not  be  confused  with  myx- 
cedema,  since  in  the  former  changes  do  not  occur  in  the  hands  and 
feet,  and  there  is  an  absence  of  mental  symptoms.  Ordinary  adi- 
posis also  affects  the  hands  and  feet.    It  is  not  painful. 

Pathology. — This  consists  in  deposition  of  fat  as  described, 


VASO-MOTOK    AXD    TEOPHIC    DISOEDERS       325 

ill  all  probability  due  to  a  central  trophic  disturbance.  Degenera- 
tion of  the  ultimate  nerve  filaments  has  been  found  by  Burr  and 
McCarthy,  of  Philadelphia. 

Prognosis. — This    condition    may    last    for    many    years,    the 
patient  dying  of  asthenia  or  fatty  degeneration  of  the  heart. 


Fig,   71. — Adiposis  Dolorosa  in  a  Colored   Woman.     (Medico-Chirurgical 

Hospital. ) 


Treatment. — Hygienic  measures  are  to  be  employed;  living  in 
the  open  air,  the  use  of  thyreoid  gland  extract,  and  massage  may 
all  prove  of  value  by  aiding  catabolism. 


326  TEEATISE    ON    NERVOUS    piSEASES 

FACIAL    HEMIHYPERTROPHY 

This  is  a  condition  of  overgrowth  of  the  soft  tissues  and  bones 
of  one  side  of  the  face,  being  the  exact  opposite  to  that  of  facial 
hemiatrophy^.  Care  must  be  observed  not  to  confuse  this  affec- 
tion with  facial  hemiatrophy,  in  which  the  normal  side  would  be 
mistaken  for  the  atrophied  side  of  facial  hemiatrophy  (see  below). 

Pathology. — It  is  supposed  to  be  a  trophic  disturbance  of  the 
central  nervous  system.     The  tissues  are  hypertrophied. 

'FACIAL    HEMIATROPHY 

Is  a  disease  characterized  by  progressive  wasting  of  the  tissues, 
particularly  of  the  bones  on  one  side  of  the  face ;  starting  in  child- 
hood, but  in  some  instances  at  middle  life.  It  usually  begins  dif- 
fusely, but  in  some  cases  at  a  single  point  on  the  skin  and  grad- 
ually spreads,  involving  at  first  the  subcutaneous  tissues,  then 
the  muscles  and  bones,  and  particularly  the  upper  jaw.  The 
atrophy  is  sharply  limited  at  the  middle  line,  the  face  looking 
as  though  it  was  made  up  of  two  halves  from  different  persons. 
The  colour  of  the  skin  changes  and  the  teeth  fall  out,  due  to  the 
wasting  of  the  alveolar  processes.  Even  the  orbit  is  seen  to  become 
atrophied  on  the  affected  side,  and  the  eyeball  may  become 
shrunken.  There  are  instances  on  record  in  which  the  disease  was 
bilateral,  and  in  a  few  cases  where  the  atrophy  extended  to  the 
back  and  arm  of  the  same  side,  the  face  was  also  affected.  It  is  a 
rare  affection,  only  97  cases  being  gathered  from  literature  by 
Sachs,  of  New  York. 

Pathology. — In  one  of  the  few  autopsies  made  by  Mendel  he 
determined  the  terminal  stage  of  interstitial  neuritis  in  all  the 
branches  of  the  trifacial  nerve  from  their  origin  to  the  periphery, 
more  severe  in  the  superior  maxillary  division.  In  a  case  reported 
by  Homen  a  tumour  was  found  pressing  on  the  Gasserian  ganglion. 

Diagnosis. — This  is  not  difficult,  since  the  appearance  is  most 
striking.  Facial  asymmetry  associated  with  wry-neck,  which,  devel- 
oped in  the  early  childhood,  is  the  only  disease  with  which  it  may 
be  confounded.    The  torticollis  would  make  plain. 

Treatment. — There  is  no  treatment  known  at  the  present  time 
that  has  a  curative  tendency  in  this  affection.  The  hygienic  care 
of  the  patient  should  be  very  strictly  pursued  as  well  as  supportive 


VASO-MOTOE    AND    TROPHIC    DISORDEES       327 

measures,  and  no  doubt  the  progress  of  the  disease  can  be  pre- 
vented to  some  extent  in  a  few  instances. 

DERMATITIS  GANGRENOSA  NERVOSA 

Gangrenous  dermatitis  of  nervous  origin  is  a  trophic  affec- 
tion, coming  on  suddenly  and  periodically.  In  individuals  of  neu- 
rotic stock  it  is  most  commonly  seen,  and  sometimes  it  is  present 


Fig.    73. — Dermatitis  Gangrenosa    Nervosa,  showing   Scars  on  Dorsum  of 
Left  Hand  op  Young  Woman,  the  Result  of  this  Disease. 

in  patients  that  are  of  good  health  otherwise.  The  attacks  of 
superficial  gangrene  in  this  rare  disease  the  record  of  the  follow- 
ing case  will  well  demonstrate: 

A.    B.,    aged    twenty-six,    white,    hysterical,    but    of    good 


328 


TEEATISE   OX   NEEYOUS   DISEASES 


physique,  no  organic  disease  existing  at  any  time.  During  one 
night  she  may  develop  patches  of  irregular  serpiginous  dry  gan- 
grene of  the  superficial  layer  of  the  derma  upon  the  hands  and 
trunk.  This  change  is  most  striking,  and  may  occur  during  a 
single  night.  The  sphacelus  sloughs  off,  leaving  chronic  ulcera- 
tion, which  heals  sloivly  under  antiseptic  treatment  within  a  few 
weeks.    There  is  no  constitutional  disturbance  at  any  time. 

Pathogenesis. — These  cases  are  very  difficult  to  explain,  but 
they  must  depend  upon  some  transient  trophic  functional  disturb- 
ance of  the  central  neuron,  vsdth  probably  an  auto-intoxication; 
the  fundamental  cause  being  instability  of  the  central  nervous 
system. 

Prognosis. — The  patient  may  live  for  many  .years  suffering 
from  recurrent  attacks,  and  finally  recover  altogether. 

Treatment. — This  is  largely  prophylactic  in  that  of  upbuild- 
ing the  nervous  system  (perhaps  by  rest-cure).     Change  of  scene, 

outdoor  life,  and  hypernu- 
trition  may  avail  towards 
preventing  attacks. 

MYXCEDEMA 

This  is  a  disease  char- 
acterized bymyxoedematous 
degeneration  of  the  subcu- 
taneous tissues  in  youth 
or  adult  life.  It  occurs 
more  frequently  in  males. 
The  affection  is  due  to  dis- 
ease of  the  thyreoid  gland 
in  which  there  is  defect  of ' 
internal  secretion  of  this 
organ.  When  the  disease 
begins  in  early  life  the 
name  sporadic  cretinistii  is 
applied;  and  when  it  oc- 
curs as  the  result  of  extir- 
pation of  the  thyreoid 
gland  it  is  designated  cachexia  strumipriva.  Myxoedema  occurs 
more  frequently  from  about  the  thirtieth  up  to  the  fortieth  year  of 


Fig.  73. — Sporadic  Cretinism 
Hospital.) 


(Philadelphia 


VASO-MOTOE    AND    TEOPHIC    DISOEDERS        329 

age.  It  may  follow  erysipelas^  rheumatism,  persistent  hemor- 
rhages, or  syphilis. 

Symptoms  are  of  mental  obtundity  with  the  physical  sign  of 
enlargement  of  the  body  through  a  universal  deposit  of  myx- 
oedematous  degenerative  material  in  the  subcutaneous  tissues.  The 
patient  seems  fleshy,  but  the  skin  is  harsh,  dry,  and  sallow-looking 
rather  than  normal  in  colour.  There  is  no  true  oedema.  The  ex- 
pression becomes  blank,  the  patient  complains  of  great  feeble- 
ness, the  lips  and  lobules  of  the  ear  and  eyelids  thicken.  The  intes- 
tinal tract  is  torpid,  the  secretion  of  the  kidneys  is  but  little.  This 
condition  exists  for  some  years  without  much  change  from  month 
to  month.  The  face  is  round,  in  contradistinction  to  the  face  in 
Paget's  disease  or  in  acromegaly.  The  hands  are  clubbed  and 
puffy,  not  "  spade-like,"  as  in  acromegaly. 

Prognosis  is  good  as  to  improvement,  wonderful  results  being 
obtained  by  means  of  the  use  of  the  thyreoid  gland  internally,  this 
making  up  for  the  deficiency  in  the  diseased  body. 

Treatment. — The  extract  of  the  thyreoid  gland  may  be  given  in 
grain  doses,  three  times  a  day,  gradually  increased  until  palpita- 
tion of  the  heart  may  be  produced.  This  must  be  kept  up  from  time 
to  time  as  the  appearance  and  weight  of  the  case  will  indicate. 

SCLERODERMA 

Is  a  condition  of  diffused  or  localized  induration  of  the  skin. 
There  are  two  types :  the  circmnscrihed,  which  corresponds  to  the 
keloids  of  Addison  or  to  morphoea;  and  the  diffuse,  in  which 
large  areas  are  affected.  This  disease  affects  females  more  fre- 
quently than  males,  and  occurs  in  early  middle  life,  although  it 
is  seen  in  spurious  form  in  babyhood — the  so-called  sclerema 
neonatorum. — by  some  said  to  be  a  different  affection.  This  latter 
disease  has  occurred  only  in  the  French  and  German  races  so  far 
as  reported.    It  may  at  times  be  of  specific  origin. 

(1)  The  form  mostly  seen  in  this  country  is  the  circumscribed 
type.  The'  patches  range  from  a  few  centimetres  in  diameter  to  the 
size  of  the  hand  or  larger,  are  waxy  in  appearance,  and  to  the  touch 
hard,  brawny,  and  inelastic.  There  may  be  a  precedent  hypersemia. 
Following  these  manifestations  pigmentary  changes  of  the  skin 
occur  either  of  excess  or  absence — leucoderma.  The  sensory  dis- 
turbances are  rare.     Perspiration  is  diminished  or  absent.     This 


330  TEEATISE    OX    XEEVOUS    DISEASES 

type  is  much  more  common  in  women  than  in  men,  and  is  situated 
about  the  neck  and  sometimes  along  the  courses  of  the  nerves. 
Patches  may  develop  with  great  rapidity,  and  may  last  but  a  few 
days  or  persist  for  years. 

(2)  The  diffuse  form,  though  less  frequent,  is  more  serious.  It 
.appears  in  the  face  or  in  the  extremities.  The  patient  notices 
that  the  skin  is  unusually  hard  or  firm,  and  there  is  a  sense  of  tense- 
ness in  making  accustomed  movements.  Gradually  a  brawny  in- 
duration develops,  the  skin  becomes  united  to  the  subcutaneous 
tissues,  and  it  cannot  be  picked  up  or  pinched.  The  skin  may  look 
natural,  but  more  commonly  is  glossy,  dry,  and  unusually  smooth. 
This  form  is  apt  to  affect,  in  order,  the  upper  extremities,  the 
trunk,  the  head  or  face,  the  upper  portions  of  the  lower  extremities, 
and  least  frequently  may  become  universal.  Occasionally  sensory 
disturbances  are  found,  the  disease  may  last  many  years  and  recov- 
ery may  occur,  or  rarely  it  may  be  arrested.  Eheumatism  and  endo- 
carditis may  complicate,  or  it  may  be  associated  with  Eeynaud's 
disease  as  reported  by  Mackenzie.  The  patient  may  be  carried  off 
by  pulmonary  or  renal  disease. 

Pathology  of  the  disease  is  unknown,  probably  a  tropho-neu- 
rosis  dependent  upon  changes  in  the  arterioles  of  the  skin,  leading 
to  connective-tissue  overgrowth. 

Sderodactylie  is  the  same  disease  manifested  by  symmetrical 
involvement  of  the  fingers,  which  become  shortened,  deformed,  and 
atrophied.  Ulcerations  have  been  met  with,  also  great  deformity 
of  the  nails.  This  disease  is  occasionally  associated  with  sclero- 
derma proper. 

Treatment  consists  in  mixed  luetic  medication  and  in  thyroid 
therapy. 

AINHUM 

This  is  a  rare  condition  occurring  in  the  negroes  of  Brazil, 
India,  Africa,  and  occasionally  in  the  Southern  States.  It  is  con- 
fined to  the  toes,  usually  the  little  toe.  It  commences  as  a  furrow 
on  the  line  of  the  digito-plantar  fold,  which  gradually  deepens, 
the  under  side  of  the  toe  enlarges,  usually  without  inflammation 
or  pain,  and  the  toe  drops  off.  The  condition  may  last  for  years, 
however,  before  spontaneous  amputation  follows.  Treatment  has 
proven  futile  in  all  eases.    Antisepsis  would  be  indicated. 


VASO-MOTOE   AND    TEOPHIC    DISOEDEES       331 

ACROMEGALY 

This  is  a  distrophy  characterized  by  abnormal  enlargement 
chiefly  in  the  bones  of  the  face  and  extremities.  The  word  was  in- 
troduced by  Marie/  and  means  large  extremities.  The  disease 
occurs  as  frequently  in  both  sexes  and  usually  begins  about  the 
twenty-fifth  year,  although  it  has  occurred  much  later.  Syphilis, 
rheumatism,  and  the  specific  diseases  have  preceded  the  develop- 
ment of  this  malady,  but  probably  have  no  special  connection  with 
it.     Disease  of  the  pituitary  body  is  said  to  be  causative. 

Symptoms. — In  a  well-marked  case  the  signs  are  characteris- 
tic. The  hands  and  feet  are  greatly  enlarged;  fingers  are  sau- 
sage-shaped. The  joints  are  freely  mobile.  The  hypertrophy  is 
general  and  gives  a  spade-like  character  to  the  hands.  The  wrists 
are  frequently  enlarged,  the  arms  rarely  affected.  The  nails  are 
broad  and  large.  The  lips  and  tongue  are  enlarged.  The  head 
is  increased  in  volume  (oval,  with  base  down)  ;  the  face  more  so 
in  proportion,  which  latter  becomes  elongated  and  enlarged  in 
consequence  of  the  increase  in  size  of  the  superior  and  inferior 
maxillary  bones.  This  was  especially  noticeable  in  a  case  coming 
under  the  writer's  care,  which  was  also  accompanied  by  bitemporal 
hemianopsia  and  mental  stupor.  The  lower  jaw  in  particular 
enlarges  and  frequently  protrudes  beyond  the  upper.  The  alveolar 
processes  are  widened  and  the  teeth  separated.  The  eyelids  are  at 
times  thickened,  the  ears  greatly  enlarged.  At  times  the  tongue 
becomes  hypertrophied,  and  later  in  the  affection  kyphosis  may 
develop  and  the  bones  of  the  thorax  may  slowly  enlarge.  With  it 
all  the  skin  may  seem  quite  normal,  but  occasionally  may  become 
coarse  and  flabby,  never  having  the  dry,  harsh  appearance  of  the 
skin  of  myxcedema.  The  patient  is  depressed  in  spirits  and  phys- 
ically weak.  There  may  be  hyperidrosis,  loss  of  sexual  power,  fron- 
tal headache;  or  bitemporal  hemianopsia  due  to  ventral  pressure 
of  the  enlarged  pituitary  body  upon  the  optic  chiasm. 

Pathology. — In  addition  to  hypertrophy  of  the  bones  great 
cystic  enlargement  of  the  hypophysis  (pituitary  body)  has  been 
found.  The  disease  is  no  doubt  a  nutritional  disturbance  analo- 
gous to  myxcedema,  and  is  probably  due  to  disturbance  of  function 
of  the  pituitary  body.     Organic  change  in  nerve  tissue  is  absent. 

Diagnosis. — The  congenital  progressive  hypertrophy  of  trunk, 

»  Revue  deM6d.,  1886. 


Fig.  74— Acromegaly  in  a  Woman,  showing  Enlarged  Supra-Orbital  Kidges, 
Inferior  Maxilla  and  Hands.    (Medico-Chiruigical  Hospital.) 


VASO-MOTOR    AND    TROPHIC    DISORDERS       333 

arms,  or  legs — the  so-called  giant  growth — is  easily  recognised.  In 
.this  there  are  never  eye  symptoms. 

In  the  osteitis  deformans  of  Paget  the  shafts  of  the  long  bones 
are  involved;  and  in  the  head  the  bones  of  the  cranium,  but  not  of 
the  face,  as  Marie  states.  In  Paget's  disease  the  face  is  triangu- 
lar, with  the  base  up ;  in  acromegaly  it  is  ovoid  or  egg-shaped,  with 
the  large  pole  down;  while  in  myxoedema  it  is  round.  In  hyper- 
trophic pulmonary  osteo-arthropathy,  while  enlargement  of  the 
hands  and  feet  occur  it  is  chiefly  in  the  lower  three-fourths  of 
the  forearm  and  legs,  but  there  is  not  any  involvement  of  the 
face.     (See  below.) 

Prognosis  is  bad  as  to  cure.  Sometimes  the  patient  can  be 
bettered  by  general  hygienic  regime.  Thyreoid  extract  and  pitu- 
itary body  have  been  recommended,  and  much  good  has  resulted 
from  their  use.  Alteratives,  hot  baths,  rest,  and  sunshine  may  tend 
to  stay  the  process. 

The  liability  to  sudden  death  must  be  remembered,  as  in  the 
instance  of  a  typical  case  under  the  writer's  observation.  The  man 
apparently  died  of  heart  failure  of  reflex  origin,  he  having  fallen 
over  while  at  work,  and  when  in  average  physical  health.  No 
autopsy  was  permitted. 

HYPERTROPHIC    PULMONARY    OSTEO- 
ARTHROPATHY 

Marie  has  given  the  name  hypertrophic  pulmonary  osteo- 
arthropathy to  a  queer  disorder  characterized  by  enlargement  of 
the  hands,  feet,  and  of  the  ends  of  the  long  bones,  chiefly  of  the 
lower  three-quarters  of  the  forearms  and  legs.  The  bones  of  the 
skull  and  face  are  not  involved.  The  terminal  phalanges  are  much 
spread  with  both  transverse  and  longitudinal  curves.  The  nails 
are  also  enlarged  and  much  curved  over  the  ends  of  the  phalanges. 
Scoliosis  and  kyphosis  have  both  been  met  with.  It  is  a  chronic 
disease,  and  in  nearly  all  instances  has  been  associated  with  some 
long-standing  affection  of  the  bronchi,  lungs,  or  pleura — hence  its 
name — of  which  sarcoma,  chronic  bronchitis,  and  pulmonary  tu- 
berculosis have  been  the  most  frequent.  It  may  develop  in  those 
who  have  had  syphilis.  It  is  more  common  in  adult  males. 
Thornburn  ^  has  collected  some  30  cases  of  this  rare  disease  and 

1  British  Medical  Journal,  vol.  i,  1893. 


334  TEEATISE    OX    XERA'OUS    DISEASES 

others  have  been  reported  since.  We  have  seen  3  cases.  Dull 
pain  in  the  extremities  was  a  symptom  in  each  patient. 

Pathology. — This  is  very  obscure.  Marie  suggests  that  the 
toxins  of  the  pulmonary  disease  are  absorbed  and  irritate  bony 
and  articular  structures.  Thornburn  believes  it  is  a  benign 
chronic  tuberculous  affection.  The  nervous  system  may  be  at  the 
bottom  of  the  disease;  it  is  very  probably  a  trophoneurosis. 

Treatment  should  consist  in  combating  the  pulmonary  disease. 
The  use  of  cod-liver  oil,  hypophosphites,  and  nutrients  may  thus 
be  of  service.  Protection  of  the  parts  from  cold  is  essential. 
Ichthyol  ointment  (1  dram  to  ^  ounce)  may  have  some  soothing 
influence  through  its  sorbefacient  effect.  Antisyphilitic  treatment 
should  be  carried  out  faithfullv. 


ARTHRITIS    DEFORMANS   (Rheumatoid   Arthritis) 

etiology. — Dr.  John  K.  Mitchell,  Sr.,  contended  that  this  was 
a  trophic  nervous  disease  as  long  ago  as  1827.  There  seems  no 
better  place  to  classify  this  disease.  It  is  a  trophic  affection  in- 
volving the  smaller  joints  of  the  hands  and  feet:  occasionally 
the  larger  joints.  It  is  characterized  by  changes  in  the  cartilages 
and  synovial  membranes,  with  periarticular  formation  of  bone  and 
great  deformity  (see  Figs.  75,  76,  and'77).  The  association  of  the 
disease  with  shock,  worry,  or  grief  will  support  the  theory  of  its 
nervous  origin;  also  its  similarity  to  arthropathies,  as  of  tabes. 
The  symmetrical  distribution  of  the  lesions,  the  skin  and  nail 
changes,  and  muscular  wasting  out  of  proportion  to  the  joint  mis- 
chief point  towards  a  trophoneurosis. 

Ord  regards  the  disease  as  similar  to  progressive  muscular 
atrophy  due  to  primary  changes  in  the  cord;  or  to  peripheral  irri- 
tation, as  of  trauma  or  uterine  disease,  these  causing  secondary 
changes  in  the  cord.  Females  are  much  more  liable  to  the  disease 
than  males.  In  Garrod's  table  of  500  cases  it  occurs  in  females 
411,  and  in  males  89  times.  Exhausting  disease,  such  as  prolonged 
sepsis  or  typhoid,  may  precipitate  it. 

Symptomatology . — The  disease  may  begin  in  children  (six  to 
twelve  years),  in  old  age  but  rarely.  It  usually  originates  between 
twenty  and  thirty  years  of  age.  Hereditary  influence  favours 
early  development.  It  has  no  more  predilection  for  the  poor  than 
the  rich,  and  I  have  seen  it  in  the  most  lowly  as  well  as  in  the 


VASO-MOTOE    AXD    TROPHIC    DTSORDEES 


535 


best  stock  in  America;  though  in  Engiand  and  on  the  Continent 
the  poor,  from  given  statistics,  suffer  most.  There  are  three 
forms  of  the  disease:  (1)  The  general  progressive  form;  (2)  the 
partial  monarticular  form;  and  (3)  that  in  which  Heberdeen's 
nodosities  are  prominent.     In  the  latter  form  "  little  hard  knobs  " 


Fig.  75. —Agglutination,  Patella  to  Tibia  and  Subluxation  of  Knee,  in 
Rheumatoid  Arthritis.  X-ray  photograph  (kindness  of  Dr.  R.  P.  Cummins, 
Howard  Hospital). 

develop  gradually  at  the  sides  of  the  distal  phalanges.  These  oceui 
later  in  life  in  the  average  case  (thirty  to  forty  years  or  over). 
Such  subjects  may  have  had  digestive  troubles.  The  joints  may  at 
first  be  swollen  or  red,  especially  when  injured.  The  dorsal  sur- 
face of  the  second  phalanx  increases  in  size,  giving  the  character- 
istic appearance  of  the  joint.  Charcot  contended  that  urate  of 
soda  is  never -deposited.     These  patients  seldom  have  involve- 


VASO-MOTOE    AXD    TROPHIC    DT80EDEES        33? 

ment  of  larger  joints,  although  exceptions  do  occur.  (See  Figs. 
75  and  77.) 

Of  the  progressive  form  there  are  two  types,  acute  and 
chronic.  Many  joints  may  be  involved  at  first  in  swelling,  red- 
ness, distention  of  synovial  sheaths  and  hursse.  It  is  more  com- 
mon in  women  between  twenty  and  thirty  and  after  prolonged 
lactation  or  rapid  childbearing.  Eemissions  may  occur.  The 
chronic  form  is  the  most  frequent.  Pain  on  movement  and  slight 
swellings  due  to  effusion  into  joints  and  the  periarticular  sheaths 
are  the  first  symptoms?.  Pain  is,  however,  an  extremely  variable 
symptom.  Gradually  the  shape  of  the  joints  is  greatly  altered, 
partly  by  the  great  thickening  of  the  ligaments,  and  still  more  by 
retraction  and  atrophy  of  the  muscles. 

Crepitation  can  be  felt  on  movement  due  to  eburnation  of  the 
articular  surfaces.  The  joints  finally  become  completely  locked, 
not  by  true  ankylosis,  but  by  the  osteophites,  which,  as  Osier  de- 
scribes, are  like  the  ring  bones  in  horses.  Spurious  ankylosis  may 
occur  also  from  thickening  of  the  capsular  ligaments  and  by 
fibrous  adhesions.  Contractures  and  contractions  occur  and  bring 
about  most  marked  flexion  of  legs  upon  the  thighs  and  the  thigh 
upon  the  abdomen.  In  other  cases  the  muscular  wasting  is  so 
rapid  that  central  disease  will  again  alone  explain  their  pathology. 
Fortunately  in  some  cases  the  fingers  and  toes  are  not  so  much 
involved,  and  the  patient  is  able  to  knit,  etc.  Numbness,  tingling, 
pigmentation,  and  glossiness  of  the  skin  exist.  In  the  worst  cases 
all  the  joints  of  the  extremities  become  loched  and  the  patient  lies 
curled  up  in  hed  helpless.  Conservatism  of  nature  and  compensa- 
tory function  are  beautifully  demonstrated  in  some  of  these  pro- 
nounced cases,  however;  the  patients  frequently  accomplishing 
under  great  difficulties  many  artistic  designs  where  the  talent 
exists. 

The  partial  or  monarticular  forms  are  found  mostly  in  the 
aged,  and  are  particularly  seen  in  the  knee,  hip,  shoulder,  or  spinal 
column  (spondylitis  deformans).  (See  Ehizomyelique  Spondyl- 
itis.) If  in  the  hip,  the  term  morbus  coxce  senilis  is  applied  to 
the  affection.  Injury  frequently  precipitates  cases  involving  one 
joint.  This  form  occurs  particularly  in  men.  We  have  one  such 
ease. 

Diagnosis. — Arthritis  deformans  should  not  be  confused  with 
rheumatism  or  gout.  The  monarticular  form  of  simple  local 
23 


Fig.  77— Rheumatoid  Arthkitis  with    Co-ntkactures.     Bedridden 
girl  before  operation.     (Howard  Hospital.)     (See  Fig.  78.) 


Fig.  78.— Rheumatoid  Arthritis,   after  Operation  and  Braces 
AKE  Applied.     (Howard  Hospital.)    (See  Fig.  77.) 


340  TREATISE    ON    NERVOUS    DISEASES 

arthritis  is  characterized  by  more  pain  than  in  arthritis  defor- 
mans, also  by  thickening  of  the  capsule  and  the  ligaments,  and  if 
neuritis  exists  with  it,  a  greater  wasting  of  the  shoulder-girdle 
muscles.  Arthritis  deformans  also  differs,  from  chronic  rheuma- 
tism in  the  existence  of  extensive  structural  alterations  especially  in 
the  cartilages,  according  to  Adams.  Pathologically,  too,  the 
changes  in  the  joints  differ  essentially  from  those  of  gout  in  the 
absence  of  deposits  of  urate  of  soda.  No  definite  microscopic 
change  has  been  found  in  the  spinal  cord  in  arthritis  deformans, 
although  there  must  be  some  morbid  physiological  process  here  as 
a  causative  factor  of  this  singular  affection. 

Treatment. — It  is  an  incurable  disease.  Much  can  be  done 
towards  alleviating  the  sufferings,  however,  or  to  arrest  its  prog- 
ress. Iodide  of  potassium  or  sodium,  quinine,  the  salicylates,  and 
arsenic  are  all  valuable.  The  use  of  tonics,  and  particularly  the 
hypophosphites,  is  of  value  in  supporting  the  system  and  in  sup- 
plying the  waste  of  salts  from  the  nervous  tissue.  Syrup  of  the 
iodide  of  iron  I  have  found  one  of  the  most  useful  drugs  to  cor- 
rect anaemia,  and  with  restored  blood  pabulum  the  progress  of  the 
disease  is  often  stayed.  Morphine  in  small  doses  by  the  mouth 
often  has  a  favourable  effect  upon  pain,  and  in  some  unknown 
fashion  may  tend  to  check  the  affection.  Bloodless  operation  of 
extension,  or  a  tenotomy,  are  means  to  help  these  people  to  get 
about  on  their  feet.  The  accompanying  illustrations  show  well  a 
girl  who  had  been  bedridden  for  two  3'ears,  a  helpless  cripple. 
She  now  is  able  to  walk  about  alone,  first  having  had  hyperex- 
tension  and  tenotomy  performed  by  Dr.  C.  H.  Frazier,  then  casts 
applied,  and  finally  braces^ adjusted.  The  ankles  and  feet  were  free 
of  disease.    The  back  cases  offer  little  help  from  the  surgeon. 

HEAT    EXHAUSTION 

This  is  a  collapse  induced  by  excess  of  heat  to  the  body,  induced 
through  natural  telluric  conditions,  or  by  artificial  heat,  as  an 
overheated  room.  It  is  generally  associated,  however,  with  the 
state  produced  by  the  excess  of  sun-rays.  The  condition  heat  ex- 
haustion is  allied  to  sunstroke,  the  clinical  difference  being  in  the 
aetiology — i.e.,  the  heat  has  not  been  so  intense  as  a  rule  or  the 
patient  is  more  resisting;  and  secondarily  in  the  symptomatology 
in  particular:  heat  exhaustion  being  a  complex  where  there  is 


VASO-MOTOK    AXD    TEOPHIC    DISOKDEES       341 

subnormal  temperature  of  the  body,  feeble  pulse,  a  status  much 
allied  to  shock,  the  patient  being  attacked  rather  suddenly.  He 
complains  of  headache  and  faintness,  and  occasionally  he  may  lose 
consciousness  for  a  short  time.  The  duration  may  be  from  an 
hour  or  so  to  many  hours.  The  pathology  merely  consists  of  a 
disturbance  of  the  heat  centres  and  vaso-dilatation  through  the 
development  of  toxins,  on  account  of  superheating  of  the  body. 

-  Prognosis. — This  is  good  if  the  patient  is  not  re-exposed  to  the 
heat,  and  fatty  heart  or  nephritis  are  absent. 

Treatment. — This  is  the  same  as  in  shock — ammonia,  strych- 
nine, and  quietude. 

SUNSTROKE 

Thermic  fever;  Heat-stroke ;   Coup  de  soleil ;  Insolation 

This  is  due  to  a  more  intense  or  more  prolonged  application 
of  heat  to  the  body,  as  seen  under  the  heading  of  heat  exhaustion. 
The  symptoms  consist  of  a  feeling  of  congestion  of  the  brain,  mud- 
dled thoughts,  as  the  patient  will  tell  you  afterward,  and  a  sense 
of  extreme  weakness,  he  usually  falling  over  at  his  occupation  into 
an  unconscious  state  in  this  period.  He  may  pass  at  once  into 
severe  tonic  and  clonic  convulsions.  The  temperature  rises  to 
102°  or  103°  F.,  gradually  increasing  until  it  may  reach  109°  or 
more ;  the  highest  case  authenticated  and  followed  by  recovery 
being  112°  F.  Urffiinic  symptoms  usually  complicate  the  disease, 
due  to  the  fact  that  the  renal  circulatory  apparatus  is  disturbed, 
and  occasionally  marked  transient  albuminuria  will  be  ■  found. 
The  duration  of  the  affection  is  apt  to  be  short  and  fulminating, 
ihe  i^atient  either  recovering  after  a  few  daj^s  or  death  may  super- 
vene before  this  time.  In  those  cases  that  recover  there  is  a  great 
liability  for  relapse  or  for  a  chronic  meningitis  to  be  set  up. 

Prognosis.'^ — Cases  with  prolonged  unconsciousness  or  suffer- 
ing from  a  high  temperature  usually  prove  fatal  in  75  per  cent  of 
the  cases.  Cases  with  high  tem_perature  and  preservation  of  men- 
tal faculties  are  more  favourable.  When  there  is  a  failure  of  the 
kidney,  determined  by  carefully  examining  the  urine,  the  prognosis 
can  be  put  down  as  also  being  bad.  In  every  case  there  is  a  great 
liability  to  relapse  on  slightest  exposure,  and  in  a  great  number  of 

^  The  statements  in  this  paragraph  are  made  from  a  careful  study  of  30 
cases  at  St.  Agnes's  Hospital  in  1896. 


342  TREATISE    ON    NERVOUS    DISEASES 

cases  there  is  a  great  liability  to  heat  exhaustion  or  sunstroke  at 
subsequent  periods.    Chronic  headache  usually  follows. 

Pathology. — There  must  be  some  chemical  change  in  the  body 
causing  paralysis  of  the  centres;  thus  more  heat  is  produced  than 
normally. 

In  those  cases  that  recover  there  is  a  great  liability  for  a 
chronic  meningitis  to  be  set  up  in  time,  which  may  be  incurable. 

Treatment. — This  consists  in  the  application  of  cold;,  prefer- 
ably moist  cold,  in  the  form  of  an  ice-bath.  This  should  be  asso- 
ciated with  friction  to  the  extremities  with  ice.  The  head  should 
particularly  be  kept  cold  in  order  to  prevent  aggravation  of  the 
cerebral  congestion.  Antipyretics  are  of  value  in  sthenic  cases. 
Convulsions  must  be  controlled  by  the  use  of  chloral  and  bromides, 
given  per  orum,  or  per  rectum  in  the  instances  where  the  patient 
cannot  swallow.  Rectal  feeding  should  also  be  employed  in  those 
cases  where  the  stomach  is  irritable,  and  in  all  cases  the  food  should 
be  simple,  such  as  peptonized  milk,  etc.  The  patient  would  better 
change  his  occupation  to  prevent  recurrence. 

MYASTHENIA  GRAVIS 

By  this  disease  is  meant  the  peculiar  condition  in  which  the 
patient  loses  power,  periodically  and  suddenly,  in  the  muscles  with- 
out any  definite  neurological  symptoms.  It  is  closely  allied  if  not 
identical  with  periodic  paralysis,  as  described  by  Taylor,  of  Bos- 
ton, and  studied  also  by  J.  K.  Mitchell,  of  Philadelphia. 

The  symptom  is  palsy;  the  patient  on  waking  in  the  morn- 
ing finds  that  he  is  unable  to  move  the  muscles  of  certain  parts 
of  the  body  or  of  the  entire  voluntary  musculature.  This  may  last 
for  a  few  to  twenty-four  hours,  or  even  several  days.  In  a  very 
short  time  the  case  is  perfectly  helpless,  without  any  sensory  or 
psychic  disturbances,  save  an  indefinite  parsesthesia  or  a  mental 
anxiety  not  due  to  brain  disease,  but  to  the  fear  he  naturally  has 
of  impending  death.  The  patient  slowly  recovers  from  the  con- 
dition, and  may  go  about  his  duties  as  usual  within  the  space  of  a 
few  days,  only  to  be  stricken  down  again  at  any  time.  Undoubt- 
edly the  underlying  condition  is  an  auto-intoxication,  either  from 
waste  products  from  within  or  from  absorption  from  without. 
Study  of  the  blood  has  been  made,  and  nothing  has  been  found 
esxcepting  a  mild  leucocytosis  during  the  attack.    As  there  are  no 


VASO-MOTOE    AND    TEOPHIC    DISORDERS       343 

temperature  symjDtoms,  it  is  not  a  condition  of  sepsis,  at  all  events. 
It  is  more  likely  a  failure  of  the  normal  chemical  changes  in  the 
nervous  system,  and  therefore  inability  to  carry  on  the  function 
-of  the  neuron,  although,  the  expression  of  this  seems  to  be  alone 
confined  to  the  muscles.  It  should  also  be  mentioned  that  there 
is  no  reaction  of  degeneration,  though  the  reflexes  are  absent. 

Prognosis. — This  is  very  dubious,  and  the  disease  may  last  for 
years,  the  patient  dying  in  an  attack  or  of  some  intercurrent  affec- 
tion. Ultimate  recovery  may  take  place  in  those  individuals  where 
the  normal  metabolism  becomes  restored. 

Treatment. — This  consists  in  the  greatest  hygienic  care  as  to 
proper  nourishing,  protection  from  cold  and  dampness,  prevention 
of  overwork,  both  mental  and  physical,  and  particularly  to  dietet- 
ics. The  food  should  be  simple,  consisting  largely  of  proteids,  as 
milk,  eggs,  and  those  substances  containing  excess  of  nuclein — 
beans,  peas,  etc. — also  those  containing  iron,  such  as  spinach, 
although  the  patient  should  never  eat  too  heartily.  During  an 
attack  the  patient  should  be  kept  in  bed.  Strychnine  is  given 
in  doses  of  -^  grain  up  to  jV  gi'ain  hypodermically.  While 
venesection  would  be  a  dangerous  procedure,  the  use  of  hypoder- 
moclysis  of  salt  solution  or  even  transfusion,  if  this  can  be  prop- 
erly done,  would  be  of  great  value.  This  subject  has  not  been  suffi- 
ciently worked  up  by  the  surgeon.  It  is  to  be  recommended  as  an 
ideal  treatment  in  this  disease.  The  use  of  thyreoid  extract, 
thymus  gland,  or  even  suprarenal  extract  capsule  preparations 
sometimes  seem  to  meet  the  conditions  and  probably  be  of  value 
in  aiding  metabolism.  Bone-marrow  is  another  organic  pre'para- 
tion  that  may  be  of  value.  The  bromides  were  valuable  in  a  num- 
ber of  the  cases  coming  under  the  observation  of  Holtzapple,  which 
is  probably  due  to  restoration  of  vaso-motor  tone  in  the  motor 
horns  of  the  cord. 

FAMILY    PERIODIC    PARALYSIS' 

Cases  of  this  rare  disease  have  been  detailed  by  Putnam  and 
John  K.  Mitchell  and  others.  The  pathology  of  the  affection  is 
unknown  ;    blood    examinations    have    shown    no    characteristic 

^  The  valuable  paper  read  by  Dr.  G.  B.  Holtzapple,  of  York,  Pa.,  at  the 
meeting  of  the  Medical  Society  of  Penna.,  Sept.  24,  1903,  throws  more  clinical 
light  on  these  enigmatic  diseases  than  has  yet  been  given  to  the  profession. 


344  TREATISE    ON    NEEVOUS    DISEASES 

.changes,  nor  has  the  urine.  Some  undiscovered  toxin,  probably  of 
autochthonous  origin,  is  the  cause;  a  tendency  to  degeneration  of 
this  sort  passing  from  one  generation  to  the  next.  (See  Myas- 
thenia gravis,  from  which  it  differs  by  being  a  family  disease.) 

Symptomatology. — It  consists  of  periodic  attacks  (of  more  or 
less  sudden  onset)  of  wide-spread  flaccid  motor  palsy,  associated 
with  loss  of  knee-jerks  and  electrical  excitability,  with  little  sen- 
sory or  psychic  symptoms  of  any  kind.  The  attacks  begin  in  the 
majority  of  cases  between  the  second  and  third  decades  of  life.  In 
some  cases  there  are  prodromata,  such  as  a  feeling  of  weariness, 
formications,  numbness,  headache,  backache,  sweating,  and  loss  of 
vaso-motor  tone.  As  a  rule  the  paralysis  begins  when  the  physio- 
logic ebb  is  lowest — i.  e.,  at  night — and  continues  for  several  hours 
before  the  acme  of  the  paralysis  has  set  in.  The  legs  are  usually 
first  affected,  then  the  muscles  of  the  arms,  trunk,  and  neck  in 
severe  cases.  The  cranial  nerves  usually  escape  palsy.  During  the 
attack  there  is  loss  of  knee-jerk  and  absolute  loss  of  electrical  irri- 
tability of  the  muscles,  without  degenerative  reaction,  however. 
But  in  the  interval  between  these  attacks  the  reflexes  and  elec- 
trical irritability  are  normal.  In  some  cases  during  an  attack 
myocardial  weakness  is  found,  the  heart  may  become  dilated,  and 
hsemic  murmurs  (usually  a  mitral  systolic  murmur)  are  found. 
This  also  disappears  with  the  normal  intervals.  The  patient  is 
mentally  apathetic  during  attacks,  but  never  further  affected  as  to 
his  mind.  The  usual  duration  of  an  attack  of  transient  paralysis 
is  from  five  to  thirty-six  hours.  Eecovery  from  the  attack  takes' 
place  gradually.  Each  succeeding  attack  may  become  more  pro- 
found, leaving  the  patient  in  a  more  marked  asthenic  condition. 
It  is  incurable.  Treatment  during  attack  should  be  hypodermics 
of  strychnine  and  digitalis,  bromides,  warm  baths,  and  effleurage. 
Hypodermoclysis  of  normal  salt  solution  may  aid  recovery.  Thy- 
reoid should  be  tried.  The  disease  should  practically  be  managed 
as  is  a  case  of  myasthenia  gravis,  already  studied,  and  from  which 
it  differs  again  in  the  more  pronounced  periodicity.     (See  p.  343.) 


CHAPTEE    XVIII 

GENERAL   TOXEMIC  DISEASES  OF  THE  NERVOUS 

SYSTEM 

HYDROPHOBIA-RABIES 

Hydrophobia^  or  rabies,  is  a  convulsive  disease  induced  by  the 
virus  of  a  rabid  or  "  mad  "  dog.  The  disease  primarily  must  origi- 
nate de  novo,  more  particularly  in  the  canine.  The  infection  is 
more  frequent  in  hot  weather,  when  the  condition  of  the  blood  of 
the  animal  favours  the  growth  of  the  germ.  As  yet  this  has  not 
been  isolated.  The  name  hydrophobia  is  a  misnomer,  in  the  fact 
that  the  patient  does  not  have  the  fear  of  water,  per  se ;  but  in  the 
symptomatology  of  the  disease,  the  spasm  of  the  pharyngeal  mus- 
cles prevents  deglutition  and  makes  the  swallowing  even  of  liquids 
difiieu.lt  or  impossible.  The  usual  method  of  inoculation  in  the 
human  being  is  by  means  of  the  bite  of  a  "  rabid  "  or  delirious 
dog.  As  a  rule,  the  wound  is  slight,  so  that  frequently  little  atten- 
tion is  paid  to  the  point  of  infection.  Where  the  wound  has  been 
freely  opened  or  cauterized  immediately  after  its  inception,  the 
less  is  the  possibility  of  development  of  rabies  following  the  bite  of 
an  animal  suffering  from  hydrophobia. 

Symptoms. — Development  of  the  symptoms  of  rabies  seldom 
takes  place  sooner  than  six  weeks  or  after  three  months  from 
the  date  of  infection.  The  patient  is  suddenly  seized  with  ex- 
treme nervousness  and  excitability;  the  muscles  remain  rigid, 
especially  those  of  mastication  and  the  constrictors  of  the  phar- 
ynx; the  head  is  drawn  back  in  tonic  spasm.  The  patient  com- 
plains of  his  inability  to  use  his  extremities  well  on  account  of 
"  stiffness  " ;  the  mental  anxiety  apparently  progresses  out  of  pro- 
portion to  the  severity  of  the  disease,  and  in  these  cases,  no  doubt, 
the  apprehension  of  the  terrible  malady  produces  a  species  of 
hysterical  insanity  complicating  the  rabies.  Within  a  few  hours 
the  patient  may  go  from  the  tojiic  convulsion  into  violent  clonic 

345 


346  TKEATISE    ON    NEEVOUS    DISEASES 

spasms;  and  these  may  be  brought  on,  too,  by  slight  sources  of 
reflex  disturbance,  such  as  loud  noises,  sudden  throwing  of  light 
upon  the  patient's  sensitive  retina,  or  as  in  attempting  to  cath- 
eterize  the  patient,  which  is  sometimes  necessary,  due  to  spasm  of 
the  sphincter  vesicae;  all  of  these  reflex  convulsions  being  the 
result  of  excitation  of  the  hypersensitive  special  sense  and  general 
sensory  neurones.  The  patient's  mental  condition  gradually  be- 
comes maniacal,  and  he  tosses  about  the  bed  in  fear  and  delusion; 
there  is  a  prominent  feeling  of  impending  death  due  to  contrac- 
tion of  the  throat  muscles  and  those  of  respiration,  and  even  the 
diaphragm;  ^while  the  cardiac  arrhythmia  and  cramp  produce 
symptoms  allied  to  angina.  Any  attempt  at  swallowing,  as  before 
indicated,  will  cause  an  aggravation  of  the  throat  symptoms, 
although  the  natural  desire  to  obtain  liquids  is  really  nature's 
effort  at  producing  dilution  of  the  poison  in  the  system,  which 
is  defeated  by  the  inability  to  perform  the  act  of  deglutition. 
Opisthotonus  is  not  an  unusual  position  for  the  body  to  as- 
sume in  the  interim  of  clonic  spasm,  the  trunk  rigidity  always 
remaining,  with  but  little  relaxation;  or  the  body  may  be  drawn 
in  emprosthotonus  or  pleurothotonus,  depending  upon  the  mus- 
cles of  the  trunk  more  particularly  affected.  This  sudden  cramp- 
ing of  muscles  in  the  various  parts  of  the  body  causes  violent  pain, 
so  that  when  the  mentality  is  not  entirely  blunted  there  will 
be  produced  evidences  of  extreme  suffering  in  the  face  aside  from 
the  general  spasm  of  muscles  of  expression.  The  temperature 
rises  in  irregular  fashion  to  103°  or  104°,  and  is  proportionate 
to  the  degree  of  infection,  especially  to  involvement  of  cerebro- 
spinal meninges.  If  the  patient  does  not  die  of  exhaustion  in  the 
convulsions  at  the  end  of  the  third  day  the  paralytic  stage  sets  in, 
the  temperature  drops,  the  muscles  become  flaccid,  the  patient 
enters  into  low  muttering  delirium  in  profound  unconsciousness, 
showing  extensive  degeneration  of  the  cerebral  cortex;  finally  he 
dies  of  exhaustion,  the  heart  generally  stopping  before  respiration 
has  ceased.     Eisus  sardonicus  usually  precedes  death. 

Diagnosis. — The  only  disease  with  which  it  can  be  confounded 
is  the  one  we  shall  next  discuss,  tetanus,  symptoms  of  which,  when 
given,  will  fairly  accurately  set  aright  this  differentiation,  which 
lies  particularly  in  the  mode  of  infection  and  in  the  stage  of 
invasion  of  the  acute  symptoms.    Hysteria  may  simulate. 

Prognosis. — The  prognosis  of  hydrophobia  is  almost  univer- 


VASO-MOTOE    AND    TROPHIC    DISOEDEES       347 

sally  fatal.  Some  mild  cases  have  no  doubt  recovered  under  treat- 
ment, just  as  rarely  occurs  in  tetanus  under  the  most  active  thera- 
peutic measures. 

Treatment. — Treatment  is  preventive.  The  antitoxine  method 
discovered  by  Pasteur  is  the  only  measure  certain  of  saving 
the  patient.  It  should  be  resorted  to  immediately  upon  learning 
the  true  nature  of  the  disease  in  the  animal  that  has  been  the 
source  of  infection;  and  in  view  of  the  severity  of  the  malady, 
should  be  done  without  delay  where  there  is  even  suspicion  of 
rabies.  The  antirabies  serum  should  be  injected  according  to  the 
dosage  prescribed  by  the  laboratories  where  it  is  prepared;  that  of 
Gribier  in  this  country  being  the  most  desirable  product.  Treat- 
ment after  the  development  of  the  disease  is  entirely  sympto- 
matic, the  use  of  cannabis  indica,  of  the  Calabar  bean,  the  bro- 
mides, and  chloral  being  indicated.  Guarding  the  patient  from 
noises  or  extremes  of  light  or  cold  is  an  essential  point  in  amel- 
ioration of  the  terrible  symptoms  of  this,  until  recently,  usually 
incurable  disease. 

TETANUS 

Lockjaw 

Tetanus,  or  lockjaw,  is  a  disease  characterized  by  violent  con- 
vulsive seizures  beginning  in  the  muscles  of  mastication ;  hence  the 
name  lockjaw.     Consciousness  is  preserved. 

Etiology. — The  cause  of  tetanus  is  a  short,  rod-shaped  bacil- 
lus, whose  habitat  is  in  the  earth.  For  this  reason  gardeners  and 
hostlers  are  particularly  susceptible  to  infection.  I  have  in  mind 
the  instance  of  a  splinter  which  produced  tetanus  when  run  under 
the  nail  of  a  farmer  while  in  his  stable ;  and  another  case  of  a  boy 
who  received  a  brush  burn  over  the  tibia  while  driving  mule-cars 
in  a  coal-shaft.  Penetrative  wounds,  as  by  a  nail,  are  also  sources 
of  inoculation.  The  incubation  of  lockjaw  is  much  shorter  than 
that  of  hydrophobia,  being  an  average  of  ten  days  until  invasion 
of  active  symptoms. 

Symptomatology  is  indicated  in  the  definition.  It  begins  with 
rigidity  of  the  jaw  (trismus);  difficulty  in  swallowing;  "stiff- 
ness "  in  the  back  of  the  neck,  the  patient  often  complaining 
at  the  outset  of  simply  an  inability  to  move  the  muscles  well  on 
account  "of  this  rigidity.  Soon  the  muscle  rigidity  becomes  gen- 
eralized, and  there  is  a  tonic  contraction  of  the  entire  muscula- 


348  TEEATISE    OX    XEEYOUS    DISEASES 

tare,  interspersed  ■R-ith  twitcliings  of  the  small  muscles  of  the  ex- 
tremities; with  this  there  is  great  mental  anxiety,  but  the  mind 
remains  perfectly  clear.  The  disease  rapidly  progresses,  clonic 
convnlsions  occur  in  which  the  patient  suffers  violent  pain  and 
cries  out  in  his  torture,  although  efforts  at  clear  phonation  are 
interfered  with  by  spasm  of  the  phar}Tigeal  and  laryngeal  mus- 
cles. There  is  forcible  dejection  of  urine  and  faeces,  also  abort- 
ive efforts  at  vomiting.  With  sudden  noises,  as  the  slamming  of 
a  door,  or  throwing  of  light  upon  the  patient,  the  subject  will 
go  into  violent  convulsive  seizures  of  a  clonic  nature.  The 
patient  will  be  at  times  painfully  contorted  in  various  parts  of  the 
bodv.  the  picture  finally  ending  with  general  convulsions,  as  above 
stated.  There  is  a  continuous  tonic  contraction  during  the  active 
course  of  the  disease.  There  is  general  hypersesthesia,  and  also 
enormous  excitability  of  the  special  senses,  such  as  photophobia, 
etc.  At  intervals  between  the  serious  motor  explosions,  and  even 
under  the  effect  of  enormous  doses  of  depresso-motors,  the  patient 
may  get  a  few  moments  of  disturbed  slumber,  only  to  be  aroused 
by  a  sudden  convulsive  attack.  The  progress  of  the  case  is  grad- 
ually downward,  the  patient  finally  at  the  end  of  three  or  four  days 
going  into  collapse,  with  slight  relaxation  of  the  muscles  and  drop- 
ping of  the  temperature  below  normal.  The  algid  stage  now  super- 
venes, also  risus  sardonicuSy  death  soon  following  from  exhaustion. 
[CepJialic,  or  Rose,  tetanus  is  a  chronic  form  of  subacute  tetanus 
in  which  trismus  is  the  prevailing  symptom.  The  course  is  longer 
(weeks),  prognosis  good,  and  treatment  (same  as  tetanus)  usually 
curative.  A  case  of  Eose  tetanus  under  my  care,  that  of  a  physi- 
cian, caused  by  a  kick  on  the  nose  by  a  mule,  recovered  promptly.] 
Treatment  is  as  yet  but  symptomatic  and  very  unsatisfactory, 
since  the  cultivation  of  the  tetanus  bacillus  cannot  be  grown  out- 
side of  the  human  body :  also,  as  we  have  not  been  able  to  produce 
the  disease  in  mild  enough  form  in  the  lower  animals  to  avoid 
death,  the  antitoxine  has  not  been  obtained.  With  the  rapid  ad- 
vances in  bacteriology,  it  is  to  be  hoped  that  such  antitoxine  will 
be  produced  in  the  *near  future,  when  we  will  have  .a  prospect  of 
successful  treatment  of  thi?  terrible  malady.  The  treatment  at 
present  to  be  adopted  is  immediately  to  open  up  a  wound  where 
from  the  above  pointed-out  sources  of  infection  any  such  wound 
exists.  Even  after  the  tetanic  symptoms  have  developed,  it  would 
be  wise,  though  late,  to  excise  such  a  wound  in  the  hope  of  sta}-ing 


VASO-MOTOR    AND    TEOPITIC    DISORDERS       349 

further  infection  from  the  nidns.  The  patient  suffering  from 
tetanus  should  be  placed  in  the  quietest  possible  surroundings; 
the  room  should  be  thoroughly  shaded  and  kept  entirely  quiet 
from  all  sources  of  reflex  irritation  through  the  general  or  special 
senses ;  the  slamming  of  a  door  I  have  seen  the  cause  of  precipitat- 
ing a  convulsion.  Chloral  is  in  my  experience  one  of  the  best 
drugs  at  command  for  the  alleviation  of  convulsion,  and  vi^hile  the 
heart  may  be  depressed,  the  excito-motor  system  is  so  stimulated 
in  this  disease  that  the  use  of  such  depressant  far  surpasses  any 
ill  effect  upon  other  organs,  as  the  heart.  This  drug  can  be  given 
in  15-grain  doses  every  three  hours,  and  pushed  until  some  amel- 
ioration of  the  convulsive  seizure  obtains.  The  remedy  can,  in  cases 
where  the  patient  is  unable  to  swallow,  be  administered  per  rec- 
tum, and  in  this  case  should  be  given  in  about  twice  the  dose  as 
when  taken  by  the  mouth.  Bromides  take  second  place  in  the 
management  of  the  disorder,  and- can  be  combined  with  the  chlo- 
ral in  eases  where  the  former  fail.  By  such  combination  we  have 
ideally  what  H.  C.  Wood  terms  the  "  crossed  "  action  of  drugs — 
that  is,  the  maximal  effect  upon  one  part  of  the  system,  in  this 
case  the  depression  of  the  motor  centres  in  the  brain,  with  a  mini- 
mal effect  upon,  as  in  this  case,  the  cardiac  and  respiratory  func- 
tions. Morphine  should  be  used  hypodermically  with  caution 
where  the  case  is  in  a  status  of  convulsions,  the  idea  being  here 
to  quiet  the  nervous  system  quickly  in  order  to  prevent  death 
through  continuation  of  convulsions  and  consequent  exhaustion. 
This  drug  should  not  be  used  in  the  interim,  since  it  is  not  de- 
sirable to  block  the  kidneys  in  any  way.  Venesection  in  tetanus 
would  seem  to  be  rational  therapeutics,  for  by  this  measure  we 
could  hope  to  carry  off  the  toxine  in  part,  and  by  hypodermo- 
clysis  possibly  to  dilute  the  blood  pabulum  and  flush  out  the 
toxine  from  the  nerve-centres  in  the  brain  and  cord.  The  prin- 
cipal drawback  in  the  procedure  would  be  the  tonicity  and  spasm 
of  the  muscles  and  blood-vessel  walls  which  prevent  both  the 
egress  and  ingress  of  salt  solution.^  Calabar  bean  I  have  seen 
cure  one  case.  It  should  be  pushed,  in  the  form  of  the  fluid 
extract,  to  the  physiological  limit  in  eases  where  the  chloral, 
bromide,  and  opium  treatment  outlined  has  failed  to  produce 
any  amelioration  of  symptoms  within  the  first  twenty-four  hours. 

1  Normal  salt  solution  is  prepared  by  adding  46  grains  of  sodium  chloride 
to  the  pint  of  distilled  water.     The  water  is  kept  at  110°  F. 


350  TKEATISE    OX    NEEVOUS    DISEASES 

It  should  be  mentioned  that  such  patients  ought  to  be  espe- 
cially guarded  from  hurting  themselves,  for  while  they  are  per- 
fectly conscious  and  appreciate  the  terrible  suffering,  they  are,  of 
course,  unable  to  protect  themselves  from  injuries  resulting  from 
the  violent  convulsions.  The  tongue  should  be  particularly  guard- 
ed from  being  bitten,  and  the  saliva  should  be  kept  clear  from  the 
tliroat,  more  by  the  posture  of  the  body  (preferably  placing  the 
patient  on  his  side  from  time  to  time)  than  by  any  effort  at 
mechanical  swabbing  of  the  throat.  The  bed  should  be  very  large, 
soft,  and  placed  in  the  centre  of  the  room,  so  that  attendants  can 
relieve  and  guard  the  patient  from  all  sides.  If  hyperpyrexia 
should  develop,  the  application  of  ice-bags  to  the  head  and  spinal 
column  would  be  of  value. 

TETANY   (TETANILLA) 

Tetany  is  a  subacute  or  chronic  disorder  that  is  characterized 
by  intermittent  or  persistent  tonic  contractions  beginning  in  the 
extremities  and  associated  with  parsesthesia  and  hyperexcitability 
of  the  motor  and  sensory  nerves. 

JEtiology. — It  is  a  rare  disease  in  America,  but  quite  common 
in  Europe,  especially  in  Austria.  It  is  more  common  at  the  sec- 
ond to  fourth  years  of  life,  and  again  at  the  age  of  puberty,  and  is 
very  rare  after  fift}^  years  of  age.  It  is  more  frequent  in  males 
in  early  life.  There  is  less  difference  in  the  frequency  of  its 
appearance  in  either  sex  after  the  twentieth  year.  Eachitis  is  a 
predisposing  cause.  Exciting  causes  are  exhausting  influences,  like 
lactation,  sepsis,  fatigue,  mental  shock,  fevers,  or  exposure  to  cold 
or  wet.  Dilatation  of  the  stomach  and  absorption  of  toxines  from 
the  intestinal  tract  in  consequence,  intestinal  parasites,  and  alco- 
holism may  also  cause  the  disease. 

Symptoms. — The  attacks  are  usually  paroxysmal,  lasting  from 
a  few  minutes  to  many  hours.  In  the  continuous  eases  the  spasm 
may  last  for  days  or  weeks.  There  may  be  a  feeling  of  general 
lassitude  or  of  numbness  or  pain  in  the  extremities  for  a  short 
time  before  the  onset.  In  the  majority  of  cases  the  spasms  are 
confined  to  the  hands  alone  or  to  the  hands  and  feet.  The  fingers 
are  closely  pressed  together,  the  thumbs  adducted  and  pressed 
against  the  index-finger,  the  so-called  writing  'posture',  or  are  flexed 
into  the  palms  beneath  the  fingers,  the  so-called  "accoucheur's 


VASO-MOTOR    AND    TROPHIC    DISORDERS       351 

hand."  The  foreariu  is  flexed  and  upper  arm  adducted.  In 
the  lower  extremities  the  toes  are  strongly  flexed,  the  knees  and 
feet  extended,  the  feet  also  being  inverted.  In  bad  cases  the  muscles 
of  the  abdomen,  chest,  neck,  and  face  are  involved.  Trismus  and 
drawing  out  of  the  angles  of  the  mouth  give  a  peculiar  physiog- 
nomy to  the  patient  (risus  sardonicus).  Opisthotonus  and  dyspnoea 
may  result.  The  orbicularis  oris  and  extra-ocular  muscles  may 
develop  contractions,  closing  the  eye,  thus  adding  a  squint  to  the 
patient's  grotesque  appearance;  the  muscles  of  the  larynx  (laryn- 
gismus stridulus),  oesophagus,  and  bladder  may  be  affected.  There 
is  no  pain  unless  the  spasms  are  severe.  Fibrillary  tremors  may  be 
seen  in  the  contracted  muscles.  There  may  seldom  be  loss  of  con- 
sciousness, and  this  usually  occurs  in  the  cases  associated  with 
extreme  debility  or  gastrectasia.  Usually  the  mind  is  quite  clear. 
There  may  during  attacks  be  hyperaesthesia  of  the  skin  of  the  parts 
affected.  The  spasms  may  arouse  the  patient  from  sleep.  Fever 
is  at  times  present  in  epidemic  form.  In  such  there  must  be  some 
mixed  infection  complicating  the  case. 

(A)  In  the  intervals  between  attacks  continued  pressure  over 
a  nerve-trunk  may  bring  on  spasms  (Trousseau s  sign).  Even  a 
slight  tap  over  a  nerve  with  the  plexor  may  induce  spasm  of  the 
muscles  supplied  by  it.  Thus  tapping  over  the  facial  nerve  at  its 
point  of  exit  from  the  stylo-mastoid  foramen  will  produce  contrac- 
tion of  the  muscles  of  the  face,  particularly  of  the  lips.  This  is 
called  the  facial  phenomenon  or  Chvosieh's  sign. 

(B)  Electrical  excitability  (electrotonus)  of  the  motor  nerves 
and  muscles  is  increased,  a  feeble  current  causing  tetanic  contrac- 
tions. Instead  of  the  normal  formula  we  may  have  AnClC  or 
AnOC>KClC.  This  is  called  Erd's  symptom.  There  may  be 
a  cathode-opening  tetanus,  a  phenomenon  not  found  in  any  other 
affection.  Gowers  says  there  may  be  a  reversal  of  the  polar  for- 
mula. Thus  a  positive-pole  opening  contraction  occurs  earlier 
than  a  positive-pole  closure  contraction. 

(C)  Sensory  nerves  are  also  more  irritable  to  mechanical  and 
electrical  stimuli;  a  weak  current  passed  through  such  a  nerve 
as  the  supra-orbital  may  cause  pargesthesia  in  the  parts  to  which  the 
nerve  is  distributed.  This  is  called  Hoffman's  symptom.  The 
auditory  nerve  reacts  easily.  In  exceptionally  mild  cases  the  symp- 
tomatology of  tetany  may  be  of  parassthesia  and  stiffness  of  mus- 
cles without  real  spasms.     In  this  latter  form  Trousseau's  symp- 


352  TEEATISE    ON    NEEVOUS    DISEASES 

torn  cannot  be  elicited.  Infantile  tetany  is  less  apt  to  be  severe 
than  that  in  youth  or  adults.  Symptomatic  tetany  from  brain 
disease  must  be  differentiated  from  true  tetany  principally  by  the 
presence  of  the  brain  disease  and  trismus. 

Duration. — When  the  spasms  are  continuous  the  disease  lasts 
but  a  few  weeks,  but  when  they  are  intermittent  they  may  last  for 
months,  as  though  it  took  a  certain  time  for  the  toxine  to  be  elimi- 
nated, and  in  which  the  spasm  assisted  in  some  unknown  fashion. 
(Epilepsy  may  also  be  bettered  by  an  occasional  attack  in  toxic 
cases.) 

Tetany  usually  lasts  a  few  weeks  or  several  months.  It  is 
liable  to  recur  on  a  return  of  the  exciting  cause. 

Diagnosis. — The  disease  is  usually  told  by  the  symmetrical 
distribution,  the  hyperexcitability  of  muscles,  motor  and  sensory 
nerves.  Trousseau's  sign  is  found  in  no  other  affection;  also  it 
is  very  rare  to  find  the  "  facial  phenomenon  "  and  the  electrical 
and  mechanical  irritability  of  such  quality  in  any  other  disease. 
The  acoustic-nerve  irritability  is  also  characteristic.  Tetany 
rarely  causes  death.  Tetany  is  distinguished  from  tetanus  by 
the  intermittent  tendency  of  the  spasms,  their  feeble  character,  and 
the  fact  that  they  begin  in  the  extremities  and  extend  to  the 
trunk;  also  the  absence  of  trismus  except  very  late  in  the  disease. 
It  may  recur  annually  for  a  number  of  years. 

Pathology. — There  is  a  congestive  and  irritative  condition  of 
the  gray  matter  of  the  spinal  cord.  In  epidemic  tetany  there  must 
exist  some  infectious  poison.  In  other  cases  mucin  circulation  in 
the  blood  is  found,  as  in  that  type  due  to  thyreoid  disease  (thy- 
reoid tetany).  Eheumatic  poison  causes  other  cases  of  tetany. 
Ergot  may  produce  symptoms  resembling  tetany.  In  infantile 
tetany  the  irritation  is  due  to  cortical  affection,  to  meningitis, 
rachitic  poison,  or  to  reflex  irritation  from  disorder  in  the  gas- 
tro-intestinal  tract.  The  latter  scarcely  ever  happens  in  adults. 
Tetany  is  a  symptomatic  disease,  but  the  primary  causes  are  so 
many  it  deserves  the  distinction  of  a  name  on  clinical  grounds. 
There. is  no  definite  pathology,  no  characteristic  constant  lesions 
being  found  at  autopsy. 

Treatment. — Stop  the  cause,  having  searched  most  carefully 
for  it.  In  cases  following  the  removal  of  the  thyreoid  or  due 
to  disease  of  that  organ,  thyreoid  extract  should  be  given.  Lacta- 
tion must  be  stopped  in  adults.    Diarrhoea,  indigestion,  or  rickets 


VASO-MOTOE    AND    TROPHIC    DISORDERS        353 

should  be  cured,  or  removal  of  intestinal  parasites  if  existent. 
Symptomatically :  Rest,  nourishing  food,  tonics;  and  for  the 
spasms,  bromide  of  sodium  in  1-dram  to  3-dram  doses  combined 
with  chloral  for  its  "  crossed  action "  are  indicated.  Hyoscine 
hydrobromate,  grain  j^j^^  t.  i.  d.,  may  be  of  service;  or  valerian  or 
other  antispasmodics  may  be  employed.  Warm  baths  are  of  serv- 
ice. Digitalis  is  of  value  in  nocturnal  tetany,  as  advised  by  Gow- 
ers.  This  dose  given  at  bedtime  very  likely  acts  through  toning 
up  the  circulation  and  hastening  elimination  of  the  poison.  The 
anodal  pole  of  a  weak  galvanic  current  may  allay  the  irritabil- 
ity for  a  time.  Inhalations  of  chloroform  or  ether  may  be  neces- 
sary to  control  the  convulsive  seizures. 


23 


CHAPTER   XIX 
DRUG  INTOXICATIONS 

ALCOHOLISM-ALCOHOLIC   INSANITY 

This  is  a  disease  produced  by  indulgence  in  spirituous  liquors. 
There  are  two  sorts :  acute  and  chronic.  The  acute  is  usually 
brought  on  by  the  excessive  indulgence  at  periodic  intervals,  the 
chronic  by  the  result  of  more  or  less  constant  imbibition.  The  de- 
velopment of  these  conditions  will  depend  more  or  less  upon  the 
idiosjmcrasy  of  the  particular  individual.  Those  forms  of  alcohol 
containing  fusel  oils  are  more  apt  to  precipitate  an  attack. 

Symptoms  of  Acute  Foi'tn. — The  patient  complains  of  con- 
fusion of  ideas,  is  mentally  excited,  the  sensorium,  however,  gen- 
erally being  obtunded,  so  that  exposure  to  cold,  for  example,  is 
not  well  appreciated.  There  will  usually  be  fine  tremor  of  the 
extremities,  lips,  tongue,  in  the  acute  alcoholic  state.  The  urine 
will  be  found  to  be  of  a  high  specific  gravity  and  often  loaded  with 
uric  acid,  especially  with  those  who  have  a  lithsemic  diathesis. 
The  patient  will  complain  of  a  full  feeling  in  the  head,  often  of 
palpitation  of  the  heart  and  symptoms  of  acute  indigestion,  such 
as  nausea  and  vomiting,  followed  by  a  thin  and  watery  stool.  This 
syndrome  of  symptoms  is  followed  by  general  muscular  weakness 
and  exhaustion.  The  clinical  picture  may  last  from  a  few  days  to 
many  weeks,  depending  upon  the  continued  indulgence  in  alcohol. 
At  any  stage  of  the  disease  the  patient  may  develop  mania  a  potu 
or  delirium  tremens,  which  is  characterized  by  great  mental  and 
physical  excitement,  by  hallucinations  and  delusions,  particularly 
of  seeing  weird  objects  (the  seeing  of  snakes),  this  being  rather  a 
constant  illustration.  The  patient  also  hears  uncanny  voices  or 
may  describe  pctual  voices,  such  as  that  he  hears  people  plotting 
against  him.  With  this  there  is  a  rapid  progressive  weakness,  and 
the  patient  may  fall  into  dementia  and  death  result  from  failure 
of  the  nerve-centres  or  from  an  intercurrent  pneumonia,  especially 


ALCOHOLISM  355 

if  he  has  exposed  himself  greatly.  The  kidneys  may  fail  and  the 
pa,tient  -go  into  a  state  of  urasmia,  which  latter  will  be  the  cause 
of  death. 

Prognosis. — This  is  good  as  to  recovery  if  the  patient's  consti- 
tution is  sufficiently  vigorous,  but  the  danger  of  relapse  is  always 
probable.  Cases  of  mania  a  potu  should  be  guarded  in  prognosis, 
since  the  patient  may  die  of  a  complication,  or  a  permanent  de- 
mentia may  be  the  sequel.     Mild  cases  usually  recover. 

Pathologij. — There  is  an  alcoholic  poisoning  of  the  nerve- 
centres,  producing  a  chronic  congestion  of  the  meninges  and  the 
brain,  and  in  the  worst  cases  fatty,  degeneration  of  the  cortical  cen- 
tres or  neurones  and  the  same  parenchymatous  change  in  other 
parts,  as  the  liver  and  kidneys. 

Treatment. — This  consists  of  in  the  first  place  withdrawing 
the  drug,  which  can  be  done  in  two  ways,  (1)  suddenly  and  (3) 
gradually.  The  former  is  the  most  desired  method,  immediately 
stopping  the  alcohol,  supporting  the  system  by  means  of  strych- 
nine or  nitroglycerin ;  and  by  simple  food,  such  as  milk,  etc.  For 
the  mental  excitement,  chloral  and  bromides  in  combination  are 
indicated.  Hyoscine  hydrobromate  in  -i^-gr.  doses  hypodermically 
is  often  of  great  value.  The  gastro-intestinal  tract  should  be 
treated  carefully ;  the  use  of  the  blue-mass  pill,  5  grains,  repeated, 
should  be  resorted  to  where  the  intestinal  tract  is  sluggish.  This 
should  be  followed  by  vegetable  tonics  given  before  meals.  The 
patient  should  be  kept  quiet  and  exposed  to  sunlight  and  fresh  air 
as  luuch  as  possible.     The  kidneys  should  be  treated. 

Symptoms  of  the  Chronic  Form. — These  are  the  same  as  in  the 
acute  form  of  poisoning,  but  in  less  degree.  The  somatic  symp- 
toms predominate ;  and  the  mental  consist  of  obtundity,  or  of  de- 
mentia in  the  worst  cases.  In  others  the  mental  symptoms  produce 
the  chronic  alcoholic  insanity  or  mania,  which  is  a  type  of  excita- 
bility or  excitable  insanity  with  delusions,  and  is  probably  due  to  a 
chronic  irritation  of  the  cortex  from  meningeal  thickening  or 
patches  of  cerebral  sclerosis. 

Diagnosis  of  any  form  of  alcoholic  poisoning  will  largely  de- 
pend upon  the  history  of  the  case  and  upon  the  detecting  of  the 
drug  upon  the  breath.  This,  together  with  the  physiognomy  of 
the  patient, '  of  acne  rosacea,  or  evidence  of  congestion  of 
the  brain,  liver,  or  kidneys,  will  make  positive  the  source  of  the 
disease  wh^n  taken  with  the  symptoms  detailed. 


356  TEEATISE    ON    NERVOUS    DISEASES 

Prognosis  of  the  Chronic  Form. — The  chronic  form  is  apt, 
unless  the  drug  is  withdrawn  or  withheld  entirely,  to  end  in 
fatty  degeneration  of  the  brain,  heart,  etc.  This  fatty  degenera- 
tion of  the  organs  of  the  body  and  neuritis  will  occur  if  the 
poisoning  continues.  Chronic  alcoholic  mania  very  seldom,  if  ever, 
recovers. 

Pathology. — Congestion  of  the  meninges  of  the  brain  and  cord, 
endarteritis,  periarteritis,  and  sequent  fatty  degeneration  of  the 
brain  and  various  organs  of  the  body,  occasionally  accompanied  by 
circumscribed  ha?morrhages,  are  all  found;  as  in  pachymeningitis 
hemorrhagica  interna,  the  symptoms  of  which  are  given  in  an- 
other place.  Cloudy  swelling  of  the  kidneys,  the  heart,  and  liver 
occur ;  while  chronic  gastritis  and  enteritis  may  complete  the  path- 
ological picture. 

Treatment. — The  treatment  of  the  chronic  form  is  largely 
hygienic  and  supportive.  Alcohol  should  also  be  withheld  entirely, 
as  in  the  acute  form  of  poisoning.  Nitrate  of  strychnine  is  the 
drug  par  excellence.  It  is  best  given  hypodermically  in  -^-grain 
doses.  The  uses  of  cocaine  ^  or  strong  infusion  of  coffee  is  of  great 
value  as  a  stimulant  in  those  cases  liable  to  depression  after  the 
withdrawal  of  alcohol.  Chronic  alcoholic  insanity  will  require 
treatment  in  an  as3dum.  Eesultant  alcoholic  neuritis  has  been 
treated  under  another  heading,     (See  Neuritis.) 

TOBACCO    POISONING 

Acute  poisoning  frequently  presents  marked  symptoms  through 
reflex  nervous  influence,  such  as  tachycardia,  irregular  pulse  or 
heart,  and  palpitation  (symptoms  that  also  exist  in  the  so-called 
tobacco  heart  in  chronic  poisoning).  There  may  also  be  disturb- 
ances of  respiration,  mental  excitement,  and  tobacco  amblyopia,  the 
latter  being  common.  The  poisoning  takes  place  in  people  who  are 
smokers,  or  in  those  who  handle  tobacco  largely,  as  cigar-makers. 
The  duration  of  symptoms  may  be  indefinite,  and  will  depend  upon 
the  amount  of  tobacco  smoke  inhaled  and  the  idiosyncrasy  of  the 
patient  for  or  against  the  drug.     The  tohacco  heart  is  of  chronic 

^A.  J.  Hall  (Medical  News,  October  31,  1903)  credits  cafEeine  with  a 
physiologic  antagonism  to  alcohol  in  doses  of  gr.  j  or  gr.  ij  every  one,  two,  or 
three  hours.  The  author  contends  that  in  twenty-four  or  forty-eight  hours 
the  drug  will  effectually  quench  the  craving  for  alcohol  in  confirmed  hahitues. 


TEA,   COFFEE,   MEECUEY,   AESENIC   POISONING  357 

nature,  often  lasting  for  many  months  or  several  years  after  com- 
plete withdrawal  of  the  poison.  Cardiac  hypertrophy  may  occur 
in  it  with  all  the  physical  signs  of  heart  disease. 

Diagnosis. — This  is  to  be  made  from  chronic  tea  poisoning, 
which  is  associated  more  frequently  with  chronic  dyspepsia,  in 
which  latter  the  amblyopia  almost  never  occurs. 

Pathology. — This  consists  in  an  auto-intoxication,  which  may 
set  up  fatty  degeneration  in  various  organs  of  the  body. 

Treatment. — Withdrawal  of  the  tobacco,  and  supportive  meas- 
ures with  nutritious  diet  are  indicated.  In  tobacco  heart  it  will 
be  necessary  to  administer  vaso-constrictors,  as  digitalis,  strophan- 
thus,  etc. ;  together  with  rest,  fresh  air,  and  sunlight. 

TEA    AND    COFFEE    POISONING 

Tea  and  coffee  are  drugs  which  very  frequently  produce  symp- 
toms in  the  nervous  system.  The  symptoms  produced  are  mental 
excitement,  insomnia,  tremor,  and  irregular  cardiac  action.  These 
are  rare,  but  they  should  be  looked  after  and  attended  to  in  order 
to  prevent  bad  results.  Treatment  would  be  the  same  as  for 
tobacco  poisoning. 

LEAD,    MERCURY,    AND    ARSENIC    POISONING 

A  remote  common  result  of  these  poisons  is  multiple  neuritis. 

The  symptoms  of  lead  encephalopathy  are  special  symptoms  of 
chronic  lead  poisoning,  and  consist  of  mental  excitement  (mania), 
or  general  or  localized  cerebral  convulsions,  and  are  usually  asso- 
ciated with  marked  arterial  sclerosis  set  up  by  the  lead.  In  the 
pathology  of  this  condition  there  is  also  a  thickening  of  the 
meninges,  and  later  in  the  course  of  the  disease  there  is  a  fatty 
degeneration  of  the  neurones.  The  prognosis  of  the  disease  is  bad. 
The  patient  may  live  for  many  years,  however,  finally  passing  into 
secondary  dementia.  The  treatment  should  be  supportive  and 
eliminative,  as  potassium  iodide  for  continuous  periods.  If  the 
mental  symptoms  predominate,  then  the  same  treatment  as  in 
insanity  should  be  resorted  to. 

Mercury  and  arsenic  seldom  produce  nervous  symptoms  other 
than  the  neuritis  indicated.  The  importance  of  the  blue  line  in 
chronic  lead  poisoning  and  the  waxy  condition  of  the  skin  and  the 
ptyalism  produced  in  mercury  are  all  points  which  will  assist  in 


368  TEEATISE    ON    NERVOUS    DISEASES 

making  the  diagnosis.  In  arsenic  poisoning  a  point  to  be  taken 
into  consideration  is  the  oedema  of  the  lids  (the  lower)  of  the  eye. 
In  all  of  the  above  poisoning  symptoms  gastric  signs  may  be 
expected. 

OPIUM    POISONING 

This  manifests  itself  in  the  nervous  system  in  the  forms  of 
acute  and  chronic  poisoning. 

Symptoms  of  Acute. — These  are  slowness  of  the  pulse  and  res- 
piration; the  former  may  go  down  to  40  or  50  and  the  latter  to 
10  or  12  per  minute.  The  patient  becomes  comatose,  the  lips  and 
extremities  may  become  cold,  and  especially  the  former  blue; 
besides,  the  patient  may  be  breathing  in  a  stertorous  manner;  the 
secretions  of  the  body  are  checked,  and  the  pupils  become  con- 
tracted or  "  pin-pointed."  The  onset  is  rather  slow  and  follows 
some  hours  after  the  ingestion  of  the  poisonous  drug.  Even  in 
the  milder  cases  it  is  difficult  to  arouse  the  patient.  While  he  may 
appreciate  his  danger,  yet  the  desire  for  sleep  is  so  irresistible  that 
he  will  not  make  any  effort  to  remain  awake  even  where  there  is  no 
intended  suicide.  One  grain  of  sulphate  of  morphine  may  produce 
these  symptoms,  or  from  3  to  10  grains  of  powdered  opium,  or 
smoking  of  the  drug,  as  a  habit.  In  some  cases  from  the  reten- 
tion of  urine  there  is  soon  set  up  a  cj'^stic  irritation. 

Symptoms  of  Chronic. — The  evidence  of  chronic  opium  poi- 
soning on  the  nervous  system  is  shown  in  mental  hebetude,  vacilla- 
tion, etc.  The  patient  is  inattentive,  generally  manifesting  to 
a  marked  degree  a  condition  of  ego ;  but  is  indecisive,  and  also 
cannot,  as  a  rule,  advance  into  new  fields  of  work,  similar  to  that 
condition  existing  in  paresis.  Such  a  patient's  secretions  and 
excretions  become  scanty,  the  skin  becomes  dry  and  hard,  and  the 
physiognomy  loses  animation,  the  pupils  becoming  and  remaining 
contracted.  The  patient  may  sit  for  hours  in  a  "  dopy  "  condition, 
again  at  times  being  vivacious,  especially  after  taking  another  por- 
tion of  the  drug.  It  is  usually,  in  most  of  the  cases,  seen  to  be  the 
result  of  hypodermic  medication,  the  abuse  of  that  form  of  thera- 
peusis.  In  other  cases  smoking  of  the  drug  is  the  cause  of  the 
chronic  opium  poisoning. 

Prognosis. — This  is  rather  dubious  as  to  recovery  in  all  cases, 
since  the  patient's  condition  is  usually  so  corrupted  at  the  time  he 
reaches  this  stage  that  he  is  unable  to  resist  the  drug  which  he  has 


COCAINE    HABIT  359 

been  taking.  If  this  can  be  reduced,  however,  liability  to  cure  is 
proportionately  large.  The  patients  may  live  for  years  as  chronic 
morphine  habitues.  They  are  liable  at  any  time  to  attacks  of  con- 
gestions and  low-grade  inflammations. 

Treatment. — This  consists  in  withdrawing  the  drug  rapidly  and 
completely,  and  in  addition  supportive  measures  should  be  resorted 
to.  In  some  cases  mental  therapeutics,  as  through  hypnotism, 
suggesting  to  the  patient  while  in  a  hypnotic  state  that  he  will  not 
be  further  able  to  enjoy  the  use  of  the  drug,  will  sometimes  be  of 
avail.  Hyoscine  hydrobromate  is  the  only  drug  that  may  act  as 
a  specific.     It  should  be  given  in  full  dosage. 

COCAINE    HABIT 

The  abuse  of  cocaine  hydrochlorate  has  become  frequent  in 
recent  years.  Often  the  hahitue  has  taken  the  drug  as  a  substitute 
for  opium  or  some  of  its  alkaloids.  Or,  again,  the  habit  may  have 
been  formed  through  a  patient  having  taken  the  drug  locally  for 
relief  of  pain,  as  in  cases  of  chronic  neuralgia  of  the  branches  of 
the  fifth  nerve,  particularly  if  associated  with  chronic  disease  of  a 
tooth  or  the  alveolar  processes  of  the  maxillary  bones.  In  other 
cases  the  habit  has  been  induced  through  cocaine  sprays  in  chronic 
naso-pharyngeal  disease.  The  drug  is  usually  taken  by  applying 
pledgets  of  cotton  soaked  with  4  per  cent  or  stronger  solution  to 
the  nasal  mucous  membrane,  or  hypodermically. 

Symptoms. — The  cocaine  hahitue  usually  shows  evidence  of 
mental  excitement,  associated  with  cardiac  acceleration  or  irregu- 
larity. The  respirations  are  hurried,  more  pronouncedly  after  he 
has  recently  taken  a  dose  of  the  drug ;  when  also  marked  mydriasis, 
wakefulness,  and  a  sense  of  dimintition  of  fatigue  and  hunger. 
The  patient  may  complain  of  a  sense  of  "  tightness  "  about  the 
chest.  The  mucous  membranes  are  dry.  In  advanced  cases  the 
skin  is  cold  and  clammy.  Other  symptoms  are  impairment  of 
co-ordination,  hallucinations,  and  delirium.  Though  decidedly 
diuretic,  it  lessens  the  quantity  of  urea  by  checking  the  processes 
of  waste,  thus  acting  as  an  indirect  nutrient,  and  enabling  the  body 
to  maintain  its  energy  on  a  lessened  supply  of  food.  On  account 
of  the  increase  of  cutaneous  circulation  local  flushings  may  occur. 
From  the  fact  that  the  hahitue  usually  tries  to  conceal  the  habit, 
observation  as  to  the  small  amounts  of  food  taken  is  important  in 
diagnosis. 


360  TEEATISE    ON"    XEEVOUS    DISEASES 

Prognosis. — The  cocaine  "  fiend  "  is  about  as  difficult  to  suc- 
cessfully treat  as  the  morphia  habitue.  Permanent  cure  is  always 
dubious. 

Treatment. — An  overdose  of  cocaine  must  be  combated  by 
amyl  nitrite  for  the  cardiac  depression,  then  alcohol  and  opium 
as  stimulants  to  the  heart ;  also  artificial  respiration.  Chloral  and 
chloroform  are  the  most  directly  antagonistic. 

The  "  habit "  is  best  combated  by  securing  full  control  of  the 
patient,  such  as  placing  him  on  rest  treatment.  The  drug  must 
be  gradually  reduced,  an  occasional  dose  of  morphia  given  in 
solution  that  the  patient  may  not  detect  the  substitute.  Digi- 
talis in  5-minim  doses  thrice  daily  or  oftener  may  be  required  to 
tone  up  the  circulation.  During  the  period  of  withdrawal  of  the 
cocaine  the  bromides  are  often  valuable  to  allay  cerebral  excita- 
tion and  produce  sleep.  The  gradual  increase  of  proteid  food,  as 
eggs  and  red  meats,  is  important  as  metabolism  recovers. 

COAL-TAR    PRODUCTS    INTOXICATION 

Under  this  heading  come  antipyrine,  antifebrine,  and  phenace- 
tine  as  true  coal-tar  derivatives,  while  the  salicylates  are  more 
strictly  of  the  carbolic-acid  series.  All  of  them,  when  used  in 
excess  in  gradually  increasing  doses,  may  be  said  to  exist  as  a 
"  drug  habit." 

Symptoms  of  Poisoning. — As  these  drugs  are  used  as  valuable 
remedies  for  pain,  the  habit  is  often  engendered  very  insidiously. 
Especially  is  this  so  in  the  hysterical  "  remembrance  pain  "  follow- 
ing true  pain  of  the  various  painful  affections  in  nervous  disease. 

There  is  usually  no  attempt  at  deception  on  the  part  of  the 
patient  the  subject  of  the  coal-tar  intoxications,  but  frequently  he 
takes  the  drug  with  a  feeling  of  its  necessity  for  the  real  or  "  re- 
membrance pain  "  referred  to  above,  and  to  which  I  have  called  the 
attention  of  the  profession  in  another  place.^  In  toxic  doses  (in 
some  cases  as  much  as  100  grains  a  day  of  antipyrine  in  tablets 
has  been  the  limit  of  tolerance)  the  patient  becomes  cyanotic, 
presenting  a  leaky  skin,  feeble,  running  pulse,  singing  in  the  ears, 
and  a  reduction  of  body  temperature  -nr"  to  -I-"  F.    Occasionally  the 

^The  Therapeutic  Status  of  the  Coal -Tar  Products  in  Central  Nervous 
Affections.  Symposium  of  the  Phila.  County  Medical  Society,  Dec.  10, 1902. 
Vol.  IV,  New  Series. 


COAL-TAR    PRODUCTS    INTOXICATION  361 

patient  is  nauseated  and  vomits.  Very  rarel}^  there  is  a  peculiar 
erythematous  skin  eruption  noticed  over  the  face,  chest,  and  on 
the  sensitive  skin  between  the  fingers.  There  is  a  depressant  influ- 
ence upon  the  brain.  In  extremely  toxic  doses  the  principal  influ- 
ence is  exerted  upon  the  blood,  altering  the  shape  of  the  red  cor- 
puscles, separating  the  hematin,  and  causing  decomposition  of  that 
fluid. 

"  Diagnosis. — Confusion  cannot  be  made  with  any  other  intox- 
ication if  the  above  symptoms  are  carefully  observed. 

Prognosis. — This  is,  as  a  rule,  good  in  chronic  poisoning,  since 
the  system  has  become  somewhat  immune  to  the  poison. 

Treatment. — Of  acute  intoxication  consists  in  the  administra- 
tion of  strong  coffee,  stryehnine,  and  digitalis,  with  quietude  and 
alcoholic  stimulation.  In  chronic  poisoning,  the  withdrawal  of  the 
drug  graduall}^,  the  steadying  of  the  circulation  by  digitalis  or 
strophanthus,  quietude  (rest  in  bed),  and  full  feeding  are  all 
essentials. 


CHAPTEE    XX 

PARESIS 

GENERAL    PARALYSIS    OF  THE    INSANE-GENERAL 
PARESIS-DEMENTIA   PARALYTICA 

This  is  a  progressive  degenerative  disease  of  the  brain,  distin- 
guished by  abnormal  mental  symptoms  which  end  in  dementia, 
associated  with  physical  weakness  or  palsy ;  also  with  other  charac- 
teristic physical  signs  and  symptoms.  It  runs  a  fatal  course,  of 
about  three  years'  duration  in  the  vast  majority  of  cases. 

Etiology. — Paresis,  as  it  is  usually  termed,  is  a  parasj^philitic 
disease,  or,  as  Krafft-Ebing  metamorphorically  puts  it,  a  disease  of 
syphilization — in  consonance  with  another  fact  that  it  is  a  dis- 
ease of  modern  civilization.  A  century  ago  paralytic  dementia 
was  rare,  now  it  is  seen  frequently  at  clinics,  asylums,  and  in  pri- 
vate practise.  The  disease  is-  rare  still  in  Asia  and  Africa.  Cli- 
mate in  these  countries  must  have  some  immunizing  influence 
upon  the  system,  since  the  same  cases  may  be  as  likely  to  acquire 
paresis  if  exposed  to  specific  infection  when  in  Europe  or  Amer- 
ica. It  is  a  disease  of  indirect  heredity  to  predisposition — \.  e., 
the  patient  is  born  with  a  neuropathic  constitution,  though  it  is 
once  in  a  while  found  to  be  congenital,  occurring  in  the  very  young 
whose  parents  were. syphilitic.  It  occurs  almost  six  times  as  often 
in  the  male  as  in  the  female.  As  women  take  on  the  follies  of  men, 
we  find  the  proportion  of  cases  increasing  in  the  female  sex. 

Excessive  mental  exertion,  as  of  the  intense  mind  tension  of 
a  banker,  is  a  predisposing  cause  also,  as  is  alcoholism.  Sexual 
excess  may  deplete  the  central  nervous  system  neurones  to  such  an 
extent  as  to  greatly  predispose  to  paresis,  but  is  almost  never  an 
exciting  cause,  as  has  been  thought.  This  disease,  with  locomotor 
ataxia,  must  be  put  down  as  being  in  75  per  cent  of  cases  (more  in 
our  experience)  due  to  syphilis.  Krafft-Ebing  gives  80  per  cent 
as  being  specific ;  and  when  occurring  in  children  Zappert  makes 
362 


PAEESIS 


363 


the  proportion  of  cases  of  paresis  clue  to  syphilis  over  87  per  cent. 
Sunstroke^,  exposure,  injuries,  and  acute  diseases  are  also  exciting 
causes  in  the  minority  of  cases.  But  once  having  had  syphilis 
associated  with  any  other  of  the  causes  enumerated,  such  a  one  is 
very  likely  to  develop  paresis  in  from  eight  to  fifteen  years  after 
the  initial  lesion.  The  disease  occurs  more  frequently  between  the 
ages  of  twenty  and  forty,  most  usual  about  the  thirtieth  year.  It 
is  more  frequent  in  married  people,  and  is  found  oftener  in  city 
than  country,  for  obvious  reasons  already  inferred. 

Symptoms. — There  are  two  stages:  one  of  excitement  or  irri- 
tation, the  other  of  dementia  and  paralysis.  Substitution  for  the 
first  stage  may  be  in  a  prolonged  period  of  melancholia  or  hypo- 
chondriasis. In  other  cases  the  dementia  and  bodily  enfeeblement 
may  go  hand  in  hand  from  the  first.  The  first  type  is  the  most 
common,  although  the  opinion  is  growing  that  mental  disturbance 
is  becoming  less  in  importance  than  is  the  initial  physical  weak- 
ness. Thus  it  is  assumed  that 
paresis  is  becoming  much  > 
more  a  disease  of  the  brain 
and  cord  and  less  a  disease  of 
the  mind,  the  mental  symp- 
toms being  that  of  a  progres- 
sive dementia  from  the  in- 
cipiency  of  the  process. 

Usual  Type. — First  stage: 
The  patient  shows  unusual 
irritability  of  temper;  he  is 
annoyed  by  trifles,  his  fam- 
ily noting  the  marked  change 
in  disposition  to  the  house- 
hold;  also  a  lack  of  proper 
appreciation  of  business  rela- 
tions. He  becomes  peevish,  is 
easily  fatigued,  is  exhausted 
without  cause,  and  is  unable 
to  fix  his  attention  for  any 
length  of  time  upon  his  af- 
fairs. He  is  apt  to  be  ex- 
travagant or  make  some  foolish  error  in  judgment.  This  con- 
dition of  irritability  is  followed  by  great  exaltation.     He  becomes 


Fig.  79.— Paretic  Dementia.  Ordinakt 
Ttpe,  Second  Stage.  (Philadelphia 
Hospital,  Insane  Department.) 


364  TEEATISE    OX    XEEVOUS    DISEASES 

happy,  and  possesses  a  feeling  of  "  well-being."  He  is  effusive  of 
speech,  and  jocose  where  he  was  formerly  sober  or  reserved.  He 
develops  great  ideas,  as  of  money-making,  and  all  by  a  conglomer- 
ate mass  of  ideas,  such  as  by  a  meat-market  and  automobile  es- 
tablishment combined.  These  delusions  of  grandeur  (megalo- 
mania) are  more  or  less  periodic,  and  the  period  of  exaltation 
often  gives  place  to  outbursts  of  violence,  this  latter  being  more 
pronounced  if  he  has  developed  a  transient  dipsomania,  which  is 
not  unusual.  "\A'ithin  a  few  months  the  family  usually  solicit  aid 
of  the  physician,  and  the  patient  is  confined  in  an  institution 
where  he  can  do  himself  or  others  no  harm.  Often  under  this  re- 
straining influence  apparent  remissions  occur,  and  occasionally 
reoJ  remissions  occur,  as  in  a  case  of  the  writer's  where  ten  years 
had  elapsed  since  a  staying  of  all  symptoms  of  undoubted  paresis 
has  occurred,  the  man  still  holding  the  initial  symptoms. 

Usually,  however,  after  some  months  in  a  hospital  the  patient 
begins  to  show  marked  signs  of  dementia,  memory  becomes  worse, 
he  misplaces  objects,  forgets  recent  matters,  commits  errors  in 
figuring,  cannot  write  coherently,  or  may  make  mistakes  in  spell- 
ing or  elision  of  letters.  The  handwriting  becomes  wavering,  the 
letters  showing  irregularities  in  the  strokes. 

During  the  exaltation  period  physical  signs  develop  which  are 
characteristic.  Besides  the  difficulty  in  writing,  noted  above,  there 
is  decided  facial  tremor,  brought  out  the  more  when  the  patient  is 
told  to  close  his  eyes  and  stretch  the  muscles  of  the  face  so  as  to 
show  the  teeth.  Marked  tremor  of  the  tongue  is  present,  much 
like  that  of  acute  alcoholism.  Speech  becomes  thick;  he  stutters; 
it  is  very  difficult  to  pronounce  long  words.  These  evidences  of 
dysarthria  are  entirely  cerebral  in  origin.  The  knee-jerks  are  usu- 
ally increased.  The  pupils  are  generally  unequal;  they  are  apt  to 
react  badly  to  light,^  and  even  sluggishly  to  accommodation.  The 
fundi  oculi  are  normal. 

An  early  and  decided  weakness  of  the  sexual  function  is  found. 
The  vesical  sphincter  may  become  paretic,  allowing  "  dribbling "' 
of  urine.  Appetite  may  be  increased,  manner  of  taking  food  glut- 
tonous.    Vegetative  organs  remain  normal  until  very  late* in  the 

^  The  tnie  Argyll-Robertson  pupil,  recorded  in  the  books,  the  writer  has 
not  found  in  twenty-five  out  of  one  hundred  cases  carefully  examined.  Irreg- 
ularity and  iridoplegia  he  would  beg  to  submit  as  being  the  most  characteris- 
tic pupillary  signs  in  paresis. 


PARESIS  365 

course  of  the  disease.  The  patient  often  suffers  from  insomnia, 
or  he  may  be  subject  to  vertiginous,  syncopal,  or  pseudo-apoplecti- 
form  attacks,  in  the  latter  of  which  he  may  fall  over  and  be  a  suf- 
ferer from  hemiplegia,  lasting  for  a  iew  days  or  even  weeks.  Epi- 
leptic convulsions  may  occur.  In  rare  cases  there  is  abolition  of 
the  knee-jerks  and  ataxic  symptoms  somewhat  resembling  the  pa- 
retic stage  of  tabes.  In  such  cases  the  general  muscular  power  is 
much  diminished,  the  patient  being  unable  to  do  any  sustained 
muscular  work,  as  walking  any  distance.  True  apoplexy  may 
occur. 

In  the  second  stage  the  most  striking  sign  is  the  gradual  onset 
of  dementia.  The  patient  sleeps  much  in  da3^time  and  becomes 
more  quiet.  He  is  very  forgetful  now,  may  not  at  times  even  rec- 
ognise his  friends,  and,  of  course,  takes  little  interest  in  outside 
affairs.  He  cannot  speak  of  current  events,  forgets  the  day  of  the 
week,  etc.  He  soils  himself  at  meals,  slobbers  his  liquids,  and 
takes  no  interest  in  his  personal  appearance.  He  may  be  uncleanly 
at  the  toilet,  and  finalh^  becomes  as  dependent  as  a  small  child. 
Later  apoplectiform  attacks  occur  with  permanent  hemiplegia,  as 
noted  above.  He  may  now  gain  flesh  and  have  a  verj^  voracious 
appetite.  In  periods  of  excitement  at  this  stage  he  may  have 
delusions  of  persecution  or  slight  delusions  of  grandeur.  Tremor 
increases  and  speech  becomes  distinctly  worse.  The  average  dura- 
tion of  the  disease  is  about  three  years.  Some  may  die  within  a 
year,  or  remission  may  occur  and  the  patient  live  in  dementia 
fifteen  years  in  rare  cases.  [A  patient  of  mine  imagined  he  gained 
untold  wealth  from  day  to  day,  although  he  did  not  name  any 
specific  sum.    He  then  quickly  became  bedridden  and  helpless.] 

Dementing  Type. — In  this  form  there  is  a  primary  dementia, 
beginning  without  any  excitement.  First  there  is  lack  of  atten- 
tion to  business,  forgetfulness,  and  general  incapacity  for  work. 
The  patient  makes  mistakes  in  dates,  in  calculations;  is  good- 
natured  to  everybody  about  him,  is  passively  happy.  He  m.ay 
have  no  delusions  of  any  sort.  Somatic  symptoms  of  tremor,  fixed 
pupils,  exaggerated  reflexes,  finally  appear  and  become  characteris- 
tic. The  scanning  speech  may  appear  last  of  all  in  this  type. 
There  may  be  increase  of  phosphates  in  the  urine,  particularly 
showing  during  any  excitable  period.  Excess  of  uric  acid  we  have 
also  found  in  these  cases.  Leucocytosis  is  generally  present.  The 
red  blood-cells  become  qualitatively  changed,  there  being  a  relative 


366  TREATISE    OX    XERAT)rS    DISEASES 

increase  of  the  polynu.clear  cells,  very  much  as  shown  in  a  study 
with  Dr.  Xapoleon  Boston  ^  to  exist  in  idiopathic  epilepsy. 

Hypochondriacal  Type. — In  this  form  the  symptoms  begin  with 
those  of  hypochondriasis  and  neurasthenia.  The  patient  complains 
of  a  vague  feeling  of  distress  about  the  head,  of  hemicrania  at 
times;  also  of  pain  in  the  back  and  limbs.  One  of  my  recent 
cases  complained  most  distressingly  of  dull  pain  in  the  epigastrium, 
the  tongue  Ijeing  constantly  coated,  and  large  amounts  of  indican 
were  found  in  the  urine.  Vague  sense  of  discomfort  also  occurs, 
which  the  patient  at  his  best  (in  the  early  morning)  is  still  unable 
to  describe.  Frequently  these  are  treated  for  weeks  as  cases  of 
neurasthenia,  since  at  the  start  they  scarcely  show  any  physical 
or  mental  symptoms.  But  careful  study  of  anamnesis  will  reveal 
in  the  history  syphilitic  infection,  while  a  study  of  the  physical 
signs  will  show  the  rigid  pupils  as  perhaps  the  only  clue  to  somatic 
failure.  After  a  year  or  so  mental  unbalance  appears,  shown  in 
suspicion,  dementia,  delusions  of  persecution,  and  the  like.  Occa- 
sional outbreaks  of  violence  may  occur,  then  all  the  typical  signs — 
alteration  of  speech,  tremor,  etc. — will  follow. 

Syphilitic  Pseudo-Paresis. — In  some  cases  of  paresis  symptoms 
of  exudative  syphilis  introduce  the  disease.  The  patient  has  at 
first  palsies  of  the  eyes,  or  attacks  of  hemiplegia  with  intense  head- 
ache, followed  by  convulsions.  The  specific  exudate  is  found  to 
either  be  pressing  against  the  convexity  or  more  usually  against 
the  base.  Under  proper  treatment  resolution  of  the  granulomata 
occurs  and  the  seizures  or  paralysis  disappear,  but  it  is  now  found 
he  is  emotional,  is  excitable,  his  memory  is  impaired,  judgment  is 
weakened ;  he  has  to  live  a  quiet,  inactive  life,  giving  up  his  regu- 
lar employment  or  professional  work.  A  pronounced  dementia 
may  not  set  in  for  eight  or  nine  years  in  this  class  of  cases. 

Alcoholic  Pseudo-Paresis. — Those  who  have  for  a  long  time 
continuously  indulged  in  alcohol  or  who  have  been  debauchees  in 
abuse  of  alcohol  may  finally  develop — usually  do — a  condition  of 
mental  weakness  simulating  paresis.  I  had  a  ptatient  of  emi- 
nently nervous  temperament,  but  of  good  ancestry,  who,  follow- 
ing troubles  in  his  family,  drank,  not  so  heavily,  but  periodically, 
to  the  production  of  mania  a  potu  on  several  occasions  only.  This 
was  followed  by  a  typical  form  of  pseudo-paresis  due  to  acute 
alcoholic  intoxication. 
*  Transactions  of  the  College  of  Physicians  of  Philadelphia,  April  1,  1903. 


PARESIS  367 

In  these  patients^  there  having  beeii  no  syphilitic  infection^ 
there  is  no  true  paresis.  Such  patients  are  selfish,  at  times  become 
bestial,  while  at  all  times  thej"  show  feeble  Judgment ;  the  memory 
becomes  a  blank.  There  is  a  gradual  loss  of  the  moral  sense.  De- 
mentia progresses  slowly,  but  these  cases  are  usually  carried  off  by 
some  intercurrent  disease.  They  never  present  the  physical  signs 
nor  typical  s3-mptoms  of  true  paresis.  If  alcohol  is  withheld  they 
may  live  many  years. 

Pathologij. — Paresis  is  a  parasyphilitic  disease  (90  per  cent) 
due  to  degeneration  of  the  cerebral  neurones  from  the  syphilitic 
toxines  developed  late  in  the  luetic  malady.  There  is  first  thicken- 
ing of  blood-vessels  due  to  periarteritis,  endarteritis,  and  prolifera- 
tion into  the  perivascular  tissue.  It  is  in  doubt  whether  the  degen- 
eration of  the  nerve-cell  is  really  secondary  to  the  above  changes; 
or  is  primary,  as  is  the  case  in  tabes.  Most  authorities  cling  to  the 
latter  view,  which  is  probably  the  correct  one. 

On  examination,  the  brain  shows  thickening  and  vasculariza- 
tion of  the  dura  mater.  This  membrane  is  generally  partially 
adherent  to  the  cranial  bones.  The  brain  mass  itself  has  usually 
undergone  atrophy,  as  shown  by  decrease  of  a  few  ounces  in  weight 
over  the  normal.  There  is  also  increase  of  cerebro-spinal  fluid. 
The  pia  mater  in  the  fore  and  mid  regions  of  the  brain  is  much 
congested.  It  and  the  arachnoid  are  much  thickened.  The  latter 
is  adherent  to  the  brain  throughout,  and  when  torn  away  the  cortex 
is  found  to  be  oedematous. 

Microscopic  study  reveals  increase  of  the  connective  tissue  and 
the  neuroglia  about  the  blood-vessels  of  the  cortex,  thickening  of 
the  interna  and  all  the  vascular  coats  to  some  degree,  together  with 
degeneration  of  nerve-cells  at  all  ages.  ISTot  only  the  neurones  of 
the  gray  cortex,  but  those  of  the  medulla,  are  also  involved  in  the 
fatty  change. 

Lesions  of  the  posterior  and  lateral  columns  of  the  cord  may 
also  be  found  in  a  third  of  the  cases.  Therefore  locomotor  ataxic 
symptoms  will  be  found  in  S3i  per  cent  of  cases  of  paresis. 
(A  less  number  of  cases  of  primary  ataxia  (4  per  cent)  will 
end  in  paresis — the  third  stage  of  ataxia.  (See  Tabes.)  This  is 
due  to  the  fact  that  tabetics  usually  are  carried  off  early  by  other 
disease.) 

Prognosis. — This  is  invariably  unfavourable.  The  patient  may 
often,  however,  be  partially  restored  by  the  use  of  tonics,  gen- 


368  TEEATISE    OX    XERVOUS    DISEASES 

era!  remedial  and  hygienic  measures,  which  includes  with  particu- 
larity the  removal  of  the  patient  from  all  forms  of  excitement; 
also  the  enforcement  of  quietude.  The  use  of  specific  medication 
in  acute  early  developing  cases  after  the  luetic  infection  may  also 
tend  to  stay  the  progress  of  the  disease.  Although  the  use  of  mer- 
curials and  iodides  will  not  cure  or  stay  the  advanced  stage,  I 
have  seen  in  the  early  stage  great  good  result  from  their  use;  in 
several  cases  apparent  cures  result.  When  the  frank  typical 
symptoms  once  develop,  cure  is  impossible  at  the  present  stage  of 
our  art.  Eemissions  and  the  milder  type  of  the  affection  within 
the  last  decade  have  a  more  promising  hope  for  greater  accuracy 
in  scientific  treatment,  awaiting  only  future  development. 

Treatment. — In  the  early  developing  cases,  as  indicated,  place 
the  patient  promptly  on  antisyphilitic  treatment — K.  I.,  gr.v,  t.  i.  d., 
HgCla,  gr.  ^ig,  t.  i.  d.,  or  even  the  use  of  inunctions  of  mercurial 
ointment,  a  dram  daily.  The  patient  should  be  kept  absolutely 
under  control  by  removing  him  to  some  hospital  or  institution 
for  mental  and  physical  quiet,  with  an  abundance  of  fresh  air  and 
sunlight  about  him.  Tonic  measures,  such  as  the  use  of  the 
Brown-Secjuard  testicular  mixture  (in  glycerine),  I  have  seen  do 
good  in  stimulating  the  patient  and  aiding  metabolism  generally. 
The  use  of  the  ductless  glands,  as  thyreoid  or  adrenals,  may  also, 
by  aiding  nutrition  and  oxidation,  be  of  service  in  staying  the 
disease.  Glycero-phosphate  of  lime,  10  grains  three  times  a  day, 
I  have  seen  give  much  benefit.  The  Charcot  douche,  cold  sponge 
daily,  and  light  massage  aid  much  in  procuring  better  circulation. 
Bromides  must  be  employed  as  periods  of  excitement  indicate. 
Hyoscine  hydrobromate,  gr.  -^j  hypodermically,  is  of  great  value 
in  maniacal  outbursts.  Chloral  and  morphia  should  be  cautiously 
employed. 


APPENDIX 


DISOEDEES    OF    SLEEP 

CoNSiDEEATiON  of  the  physiology  of  sleep  and  waking  has 
been  studied  in  the  forepart  of  this  work  (Chapter  I,  pp.  42 
and  43). 

The  symptomatic  disorder,  insomnia,  has  also  been  treated  at 
length  in  another  place  (p.  126). 

Sleep  is  that  calm  to  the  nervous  system  that  supplies  nerve 
energies  for  the  workingman.  There  are  many  theories  of  the 
causation  of  sleep,  the  latest  being  that  of  retraction  of  the  proto- 
plasm of  the  cortical  neurones.  This  separating  one  from  another 
cuts  off  the  association  of  nerve  impulses  of  the  higher  centres, 
while  those  lower  more  physical  or  vegetative  functions  still  are 
active.  This  beautiful  mechanism  is  thus  well  illustrative  of  the 
possible  gross  mechanism  of  mind  action.^  It  at  least  permits 
of  better  conception  of  the  ever  mysterious  phenomena  of  sleep. 
The  causation  of  sleep  is  more  universally,  however,  considered  to 
be  due  to  ansemia  of  the  brain.  This  theory  has  its  partial  proof 
in  the  fact  that  the  blood  pressure  is  lowered  during  sleep,  as  shown 
by  sph}^mographic  tracings.  Self-developed  catabolites  may  be 
the  remote  cause  back  of  all  others;  these  autochthonous  poisons 
precipitating-  the  mechanical  status  of  the  cells  found  during  sleep. 

Given  a  healthy  mind  in  a  healthy  body,  we  have  the  highest 
type  of  man :  mens  conscia  recti.  So  that  the  wear  and  tear  of 
life  is  constantly  balanced  in  part  by  periods  of  repose,  particu- 
larly of  sleep.  There  is  never  an  absolute  repose  of  mind  or  body, 
however,  from  birth  to  death. 

There  is  nothing  so  subtle  or  important  as  the  study  of  the 
disorders  of  sleep.    In  the  first  place,  we  must  recall  that  there  is 

'  See  the  discharge  theory  suggested  by  Bechterew  (Neurol.  Centralbl.,  1896, 
N'os.  2  and  3)  ;  also  the  studies  of  Forel,  His,  and  Cajal  abroad,  and  Uercum  in" 
this  country  (Functions  of  the  Neurone,  Jour,  of  N.  and  M.  Dis.,  August,  1896). 
24  369 


370  TREATISE    ON    liERVOUS    DISEASES 

an  individuality  about  tlie  amount  of  sleep  necessary  as  a  restora- 
tive agent.  Some  nerve  protoplasm  requires  more  hours  of  sleep 
than  another.  ISTor  is  it  the  neurotic  person  that  requires  most. 
It  is  simply  a  matter  of  idiosyncrasy,  which  only,  can  be  judged 
by  the  history  of  any  case.  In  proportion  as  sleep  does  service  in 
resting  the  mind,  do  we  have  the  only  accurate  index  of  the  value 
of  a  given  slumber ;  and  yet,  as  some  one  has  well  said,  a  dreamless 
sleep  probably  does  not  occur.  We  should  reason  from  this  that 
fixing  or  a  resetting  of  our  thoughts  during  the  time  of  peaceful, 
quiet  sleep  is  one  of  its  functions.  Indeed,  too,  the  merftal  impres- 
sions thus  finally  fixed  during  sleep  are  probably  of  the  most  en- 
during nature — the  mainsprings  of  character;  for  consciousness 
brings  its  artificialities,  while  the  various  pitfalls  of  convention- 
ality are  entirely  done  away  with  in  sound  sleep,  and  the  best 
things  of  the  mind  remain  afterward.  It  is  but  the  demonstration 
of  God's  rule  as  set  down  by  Darwin,  "  the  survival  of  the  fittest." 
It  is  a  high  province  of  the  physician  to  bring  about  natural  sleep. 

A.  Wakeful  Disorders  of  Sleep 

I-nsomnia  may  be  said  to  be  the  most  important  disturbance  of 
sleep.  Its  causes  are  legion :  pain,  lack  or  excess  of  exercise, 
toxasmias,  excitement,  or  worriment.  In  the  treatment  of  it  no 
physician  can  be  successful  unless  he  seeks  out  the  fundamental 
cause. 

Pain,  if  intractable,  must  be  counteracted  by  a  dose  of  mor- 
phine. Poisons  should  be. eliminated.  Exercise  must  be  regulated 
to  oxygenate  the  blood  properly ;  a  happy  medium  for  the  indi- 
vidual ease  is  to  be  sought.  It  is  folly  to  advise  long  walks  for  the 
banker  or  a  series  of  rigid  calisthenics  for  an  overworked  lawj^er  or 
physician  or  student.  This  I  have  seen  do  almost  irreparable  dam- 
age in  a  neurasthenic  man  attending  the  regular  gymnastic  course 
in  one  of  the  leading  universities  of  Xew  York  State.  Excite- 
ment must  be  ad  minimum  in  the  sufferer  from  insomnia.  It  is 
well  also  to  arrange,  for  the  several  hours  preceding  "  bedtime," 
especial  mental  and  physical  quietude.  The  room  should  be  well 
ventilated  in  which  the  patient  sleeps.  It  should  be  dry,  prefer- 
ably in  a  room  of  northern  exposure,  since  many  are  easily  wak- 
ened, as  by  rays  of  the  rising  sun  at  daybreak.  All  extrinsic  causes, 
such  as  noises,  should  be  guarded  against.     I  have  seen  patients 


APPENDIX  371 

immediately  improve  by  being  taken  to  another  room  when  some 
particular,  though  slight,  noise,  not  thought  of  by  the  sufferer, 
was  the  cause  of  his  awakening. 

General  methods  to  employ  are  warm  water  bathing  (temper- 
ature 112°  F.),  followed  by  a  brisk  rub  with  a  Turkish  towel;  or 
light  massage,  especially  stroking  the  forehead  at  the  end  of  the 
treatment;  or  hot  milk  taken  at  the  moment  of  retiring.  Hyp- 
notism may  be  resorted  to  in  the  exceptional  case  where  hysteria 
is  the  base  of  the  trouble,  but  it  is  not  a  reliable  agent,  and  is 
liable  to  abuse. 

Where  high  arterial  brain  pressure  exists  the  cautious  employ- 
ment of  depressants,  as  aconitia,  gr.  -^^  at  bedtime,  or  several  min- 
ims of  tincture  of  aconite,  I  have  seen  of  positive  service.  But  any 
attempts  to  relieve  vascular  pressure  by  nitro-glycerine  will  aggra- 
vate the  case,  due  to  increasing  the  flow  of  blood  to  the  surface, 
and  therefore  the  meninges,  thus  causing  irritation  of  the  branches 
of  the  fifth  nerve. 

Somnambulism  is  sleep-walking,  a  state  in  which  the  patient 
acts  his  part  of  a  dream.  In  this  disorder  the  subject  passes, 
more  or  less  automatically,  through  various  apparently  natural 
phases  of  physical  and  organic  life,  without  full  mental  inhibition 
existing  as  when  the  conscious  mind  controls  him.  Somnam- 
bulism is,  to  a  degree,  evidence  of  unrest,  of  inevitable  wakeful- 
ness. I  have  a  patient  who  walks  about  at  night  frequently,  talks 
coherently  the  while  to  those  who  address  her,  but  in  the  morn- 
ing she  is  exhausted  and  remembers  nothing  of  the  phenomena. 
Thus,  too,  it  is  with  people  who  dream  constantly.  It  is  evidence 
that  the  physiological  mechanism  is  out  of  kilter,  so  to  speak, 
especially  if  the  dream  is  something  "  horrible "  or  unpleasant. 
"  Pleasant  dreams  "  are,  however,  natural  and  not  in  any  extent 
exhausting,  because  they  are  natural,  and  any  natural  event  is  a 
stimulation  of  metabolism  without  which  latter  mind  action  can- 
not be  at  its  best.  The  proverbial  saying  that  chronic  invalids 
develop  frequently  the  best  mental  and  moral  specimens  of  men 
and  women  is  not  borne  out  by  the  cold  facts,  as  physicians  so  well 
know.  They  are  good  specimens  in  spite  of  their  infirmity  only. 
Disorders  of  digestion  have  much  to  do  with  both  of  the  above 
states.  One  so  disposed  should  be  instructed  to  be  very  cautious 
about  indiscretion  in  diet.  An  hypnotic  given  at  bedtime,  prefer- 
ably trional,  grs.  xv,  or  chloralamid,  gr.  xij,  will  aid  to  prevent 


3?2  TEEATISE   OX   XERVOUS   DISEASES 

attacks  of  either.    The  hygienic  care  is,  in  other  respects,  the  same 
as  in  simple  essential  insomnia,  a  most  important  matter. 

B.  SoMxoLEXT  Disorders  of  Sleep 

These  are  the  disorders  marked  by  an  irresistible  desire  to 
sleep,  and  they  are  not  so  frequent  as  Class  A,  but  usually  imply 
the  same  grave  organic  disease  or  incurable  affection,  where  the 
underlying  pathology  is  not  as  yet  definitely  determined,  except 
in  hysteria,  which  may  simulate  any  malady. 

Ecstasy,  catalepsy,  and  trance  are  accidental  somnolent  states 
occurring  in  hysteria.  Ecstasy  is  a  more  or  less  transient  emo- 
tional state  when  the  patient  is  transfixed,  as  it  were,  in  self-con- 
templation. When  there  is  general  muscular  rigidity  associated 
for  some  period  of  "time,  catalepsy  exists.  A  trance  is  a  passive 
condition  of  quiet  somnolence  in  which  the  patient  lies  motionless 
with  all  function  at  the  lowest  ebb.  Respiration  and  pulse  may  be 
almost  imperceptible. 

The  treatment  of  these  three  conditions  will  be  that  of  the 
management  of  a  general  hysterical  state.  It  should  be  mentioned 
that  some  complex  treatment,  such  as  hypnotism,  or  a  long  series 
of  regulated  exercises  in  deep  breathing,  the  mental  and  hydro- 
therapeutic  value  of  a  cold  shower-bath,  together  with  forced  feed- 
ing to  the  constitutional  limit,  singly  or  combined,  will  offer  the 
best  rewards  in  cure  to  the  caretaking  physician. 

Sleeping  sickness,  as  recently  described  by  Manton  and  Mott  as 
due  to  filaria  and  occurring  in  certain  natives  of  Africa,  is  a 
clinical  syndrome  in  which  somnolence  appears  in  intervals  grad- 
ually increasing  until  tbe  patient  sleeps  steadily  for  many  hours. 
At  first  the  patient  can  be  aroused  sufficiently  to  take  food,  and 
finally  awakened  with  extreme  difficulty. 

In  two  cases  studied  by  Mott  ^  a  chronic  infused  leptomenin- 
gitis and  encephalomyelitis  were  found,  but  no  infectious  organ- 
ism. In  studying  the  blood  -  for  another  purpose  with  Dr. 
ISTapoleon  Boston,  this  observer  discovered  in  a   rat's  blood  an 


^British  Medical  Journal,  December,  1899. 

2  The  Blood  in  Epilepsy :  Experiments  on  Animals.  Transactions  of  the 
Physicians  of  the  College  of  Philadelphia,  March,  1903.  American  Journal  of 
Insanity,  January,  1904. 


APPENDIX 


373 


actively  motile  micro-organism  similar  to  the  one  described  by 
Manton  very  recently  as  a  probable  cause  of  sleeping  sickness. 
Upon  a  warm  slide,  with  the  lower  power  of  the  microscope,  the 
organisms  could  be  readily  seen  pushing  the  corpuscles  about.  The 
organism  has  been  designated  Tryfanosomos  Castellani  from  its 
discoverer. 

If  this  organism  is  the  cause  of  this  disease  some  form  of 
immunization  or  prophylaxis  seems  to  be  the  only  possible  hope 
for  cure  in  the  future. 

Narcolepsy  is  a  condition  in  which  the  patient  repeatedly  goes 
to  sleep  in  the  day.  It  is  a  marked  form  of  epilepsy  and  requires 
the  same  treatment  (see  Epilepsy). 

ADDITIONAL  FIGUKES 


Fig.  80.— Spastic  and  ATnExoiD  Movements  in  Face,  Tongue,  and  Pharyn- 
geal Muscles.  Case  of  Cerebral  Spastic  Paralysis.  (Philadelphia  Hos- 
pital. ) 


374  TREATISE    OX    XEEVOUS    DISEASES 


Fig.  81. — Attitude  in  a  Case  of  General  ATHEl<JSI.•^  in  Cerebral  Palsy  of 
Childhood.     (Philadelphia  Hospital.) 


APPENDIX 


375 


Fig.  82.— Secondary  Contractions  of  Face,  Arm,  Hand,  Foot,  and  Leg  in 
Case  of  Chronic  Left  Hemiplegia.     (Philadelphia  Hospital.) 


376 


TREATISE    OX    XERVOUS    DISEASES 


Fig.  83.— Tomour  (Endothelioma).  Inner  Surface  Cerebral  Dura.    (Museum 
of  Philadeliihia  Hospital.) 


xiPPENDlX 


377 


E^S' 


1i 


g  m 


u 
H 

Q 

Bh 

OJ 

=t-i 
o 

!^ 

O 

m 

a; 

H 

d 

1-1 

nS 

P 

tc 

•  i-i 

Ed 

W 

tf 

» 

Z 

a5 

c 

O 

CO 

-J 

^^ 

■< 

a 

H 

Ph 

Z 

<) 

o  o 

a 

«     CJ 

o 

fe  (1h 

S    P     bi 


fed. 


W  Hi 

2     M 


Z  O 
O  H 
2  W 


24* 


378 


TREATISE    ON    NERVOUS    DISEASES 


s     s- 


I-  —    —I 


==  » 


^ 

c 

.^  .„•  .^  •  ^ 

s 

^ ^ -^  ^^ 

fl  a  a  g  u 

(u  u  0)  s  g 

:^ 

tS 

t.  05  *;  S^S 

^ 

S 

03  ni^  =»« 

:« 

'2 

^■sa=^i 

-^ 

1-5  S  a     ~ 

c?-- 


^     W 


APPENDIX 


379 


Triceps  (long  head). 

Triceps  (internal  head). 
Ulnar.  \ 


Flexor  carpi  ulnaris. 
Flexor  profundus  digitorum. 


Flexor  sublimis  digitorum 
(II  and  III). 


Flexor  sublimis  digitorum 
a  and  IV). 

Ulnar. 

Palmaris  brevis. 

Abductor  minimi  digiti. 

Flexor  brevis  minimi  digiti. 

Opponens  minimi  digiti. 

Lumbricales 


Deltoid  (anterior 
half). 


Musculo-cutaneous 
Biceps. 
BrachiaUs  anticus- 


Supinator  longus. 
Pronator  radii  teres. 
Flexor  carpi  radialis. 


Flexor  sublimis  digitorum. 

Flexor  longus  poUicis. 
Median. 

Abductor  pollicis. 
Opponens  pollicis. 
Flexor  brevis  pollicio. 
Adductor  pollicis. 


Pig.  86.— Showing  Motor  Points.     (Shoulder  and  Arm.)     Anterior  A.spect. 


380 


TREATISE    OX    NEEYOUS    DISEASES 


Deltoid  (posterior  half). 


Radial  {musculo-spiral}. 
Brachialls  anticus 

Supinator  longus. 
Extensor  carpi  radialis  longior. 
Extensor  carpi  radialis  brevior. 


Extensor  communis  digitorum.  ^ 
Extensor  indicis 

Extensor  ossis  metacarpi  pollicis 
Extensor  primi  internodii  pollicis 


Dorsal  interossei,  I  and  II.  ^ 


Triceps  (long  head). 


i  Triceps  (external  head). 


Extensor  carpi  ulnaris. 
Supinator  brevi.s. 

Extensor  minimi  digitL 
Extensor  indicis. 


Extensor  secundi  internodii 
pollicis. 


Abductor  minimi  digiti. 

(  Dorsal  interossei, 
/      m  and  IV. 


Fig.  87.— Showing  Motor  Points.     (Shoulder  and  Arm.)    Posterior  Aspect. 


APPEXDIX 


381 


Tibialis  anticus 

Extensor  longus  digitorum 


Peroneus  brevis. 


Extensor  proprius  poUicis 


Dorsal  interossei. 


Peroneal. 


Gastrocnemius  (external). 
Peroneus  longus. 


Soleus. 


\    i'^J Flexor  loBgus  hallucis. 


Extensor  brevis  digitorum 
Abductor  minimi  digitL 


Pig.  88.— Showing  Motor  Points.     (L°g) 


383 


TREATISE    ON    NERVOUS    DISEASES 


LESION  CAUSING 
MONOPLEGIA  OF  LEG 


ORDINARY  HEMIPLEGIA, 
PARALYSIS  OF  SIDE 
OPPOSITE  TO  LESION. 


HEMIPLEGIA  OF  OPPO- 
SITE SIDE,  OCULO- 
MOTOR PARALYSIS  OF 
SAME  SIDE. 


HEMIPLEGIA  OF  OPPO- 
SITE SIDE,  PARALYSIS 
OF    FACE  AND    EXTER- 
NAL RECTUS  ON  SAME 
SIDE. ^ 


IIPPFR    MOTOP    PATH=aRFD- 

LESIONS    OF    THIS    PATH 
CAUSE  SPASTIC  PARALYSIS. 


LESIONS    OF    THIS    PATH 
CAUSE  FLACCID  PARALYSIS 


ORDINARY 

HEMIPLEGIA 


HEMIPLEGIA,  ARM 
MORE  THAN  LEG. 


HEMIPLEGIA 
WITH  HEMIATHE' 
TOSIS  AND  HEMI- 
CHOREA. 


HEMIPLEGIA,  LEG 
MORE  THAN  ARM, 
WITH  HEMIANAES- 
THESIA,  HEMIOPIA 
AND    DISTURBAN- 
ES  OF  HEARING, 
TASTE  P  AND 
SMELL  P 


ERIOR 
EXTREMITY 
OF  CAPSULE. 

.SEgl^ON  OF^  INTERNAL  CAPSULE. 

III  N.  OCULOMOTOR. 

IV  N.  PATHETICUS. 
•V  N.  TRIGEMINUS. 

VI  N.  ABDUCENS. 
■  VII  N.  FACIAL.- 


IX  N.  GLOSSOPHARYNGEAL. 
,  X  N.  PNEUMOGASTRIC. 
XI  N.  SPINAL  ACCESSORY. 


XII  N,  HYPOGLOSSAL. 


LESION    INVOLVING 
ANTERIOR  HORN  OR 
ROOT.  FLACCID  PAR- 
ALYSIS OF  MUSCLES 
AT  SITE  OF  LESION. 


TRANSVERSE  LESION 
OF  CORD,  FLACCID 
PARALYSIS  OF  MUSC- 
LES LOCALIZED  AT 
LEVEL  OF  LESION. 
SPASTIC  PARALYSIS 
OF  MUSCLES  BELOW 
LESION.  


FiQ.  89. — Showing  the  Effects  of  Various  Lesions  of  the  Motor  Path  in  the  Brain 
AND  Spinal  Cord.  The  Upper  Right-hand  Sketch  shows  the  Variations  in 
Symptoms  caused  by  a  Difference  in  the  Antero  -  posterior  Position  of  the 
Lesions  in  the  Internal  Capsule. 


APPENDIX 


383 


CVII 


VIII 


Fig.  90.— Diagram  of  Skin  Areas  corresponding  to  the  Different  Spinal 
Segments.    Anterior  Aspect.     (Combined  from  Head's  Diagrams  by  Osier.) 


384  TKEATISE    OX    XERVOUS    DISEASES 


C  VI — 


OVIII   - 


CTII 


cvu 


Fig.  91.— Diagram  op  Skin  Areas  coRRESPONDiyG  to  the  Different  Spinal 
Segments,     Posterior  Aspect.     (Combined  from  Head's  Diagrams  by  Osier.) 


APPENDIX- 
TABLES 


385 


The  difference  between  multiple  neuritis  and  poliomyelitis  is 
well  shown  in  the  following  modification  of  the  summary  by 
Starr : 


Acute  poliomyelitis 
Sudden  onset,  with  fever  and  de- 
velopment of  paralysis  in  all  the  limbs, 
followed  in  from  three  to  five  days  by 
subsidence  of  paralysis,  which  remains 
in  a  few  muscles  of  one  limb;  or,  if 
two  are  affected,  the  paralysis  is  rare- 
ly symmetrical.  If  the  onset  is  sub- 
acute, four  weeks  is  the  duration  of 
onset.  The  muscles  are  not  tender. 
Sensory  symptoms  are  rare,  and,  when 
present,  soon  subside. 


Multiple  neuritis 
Fatigue  for  some  weeks ;  then  sud- 
den onset  and  progress  for  two  weeks 
with  or  without  fever.  Legs  usually 
first  affected,  then  arms,  then  body. 
The  paralysis  has  no  tendency  to 
subside  for  some  time  (months). 
The  limbs  are  affected  symmetrically. 
Usually  there  is  tenderness  of  the 
nerve-trunks  and  affected  muscles, 
and  pain,  with  areas  of  anaesthesia. 


GowERs's  Table  of  Laryngeal  Paralysis 


Symptoms 

No  voice ;  no  cough; 
stridor  only  on  deep 
inspiration. 

Voice  low  pitched  and 
hoarse ;  no  cough ;  stri- 
dor absent  or  slight  on 
deep  breathing. 


Voice  little  changed ; 
cough  normal ;  inspi- 
r  at  ion  difiieult  and 
long,  with  loud  stridor. 

Symptoms  inconclusive; 
little  affection  of  voice 
or  cough. 

No  voice ;  perfect  cough ; 
no  stridor  nor  dysp- 
noea. 


Signs 

Both  cords  moderately 
abducted  and  motion- 
less. 

One  cord  moderately  ab- 
ducted and  motionless, 
the  other  moving  free- 
ly, and  even  beyond 
the  middle  line  in  pho- 
nation. 

Both  cords  near  together, 
and  during  inspiration 
not  separated,  but  even 
drawn  nearer  together. 

One  cord  near  the  mid- 
dle line  not  moving 
during  inspiration,  the 
other  normal. 

Cords  normal  in  position 
and  mo-ing  normally 
in  respiration ,  but  not 
brought  together  on  an 
attempt  at  phonation. 


Lesion 
Total  bilateral  palsy. 

Total  unilateral  palsy. 


Total  abductor  palsy. 


Unilateral  abductor 
palsy. 


Abductor  palsy. 


25 


386 


TREATISE    OX    XEEYOUS    DISEASES 


The  following  table  from  Sachs  shows  the  lesions  most  likely 
to  be  present,  according  to  the  time  of  onset  in  Cerebral  Palsies : 


Groups. 


f  Paralysis  of  intra- 
Diaplegia    j        uterine  onset. 

and  -] 

paraplegia  j 

L  Birth  palsies. 


Hemiplegia  I  ^^^* 


Acute  (acquired) 

sies. 


Morbid  Lesion. 


Large  cerebral  defects ;  porencephaly.  De- 
fective development  of  pyramidal  tracts. 
Agenesis  corticalis  (highest  nerve-elements 
involved). 

^Meningeal  h;emorrhage,  rarely  intracerebral 
ha^norrhage.  Later  conditions,  meningo- 
encephalitis chronica,  sclerosis,  cysts,  par- 
tial atrophies. 

Haemorrhage,  meningeal  and  rarely  intra- 
cerebral; thrombosis,  from  syphilitic 
endarteritis  and  in  marantic  conditions  ; 
embolism.  Later  conditions,  atrophy, 
cysts,  and  sclerosis  (diflfuse  and  lobar). 

Meningitis  chronica. 

Hydrocephalus  (seldom  the  sole  cause), 
primary  encephalitis,  polio-encephalitis 
acuta  (Striimpell). 


Differential  Points  of  the  Two  FoR^rs  of 

Ataxia  "' 


Family 


(I)  Friedreich's  Form 
1.  Occurs  before  puberty. 
3.  Choreiform  movements  seen  affect- 
ing head,  arm,  and  trunk. 

3.  Optic  atrophy  exceptional. 

4.  Tendon    reflexes    diminished    or 

abolished. 

5.  Club-foot  and  scoliosis  common. 


5. 


(II)  Marie's  Form 

Occurs  after  piiberty. 

Choreiform  movements  are  very 
pronounced. 

Optic  atrophy  is  common. 

Increased  reflexes  and  clonus  fre- 
quent. 

Club-foot  and  scoliosis  are  excep- 
tional. 


FORMULARY 


For  anaemia  in  neurasthenia. 

^      -D-T  T51      1  (  Ferri  sulph, 

^     Pil.  Bland  gr.Y  ]  ^  ,  ^  ,        , 

i  rotass.  carbonat aa  gr,  ijss. 

Sig. :  One  or  two  pills  ten  minutes  after  meals. 

Neurasthenia  (essential). 

^     Sod.  brom.         /  -.-      •• 

Ammon.  brom.  j   ' '        •'* 

Aquae q.  s.  ad  3  iij. 

M.  et  sig. :  Teaspoonful  every  three  hours  until  head  symp- 
toms relieved. 

l^eurasthenia  (insomnia  of). 

5     Trional 3  ij. 

M.  et  ft.  chart  Xo.  x. 

Sig. :  One  at  nine  o'clock  in  hot  milk. 

Neurasthenia  (sexual). 
5     Ferri  valerianat  \ 

Zinci  valerianat    >   aa  gr.  xxiv. 

Quin.  valerianat  ) 
M.  et  ft.  pil.  Xo.  xxiv. 
Sig. :  One  after  meals. 

Also  neurasthenia  (sexual)  "with  irritable  bladder. 

^     Potass,  citratis 3  iij. 

Essence  pepsini fl.  §  j. 

Aquae  cinnamonii ?  iij. 

M.  et  sig. :  Teaspoonful  every  three  hours. 

For  nervous  cough. 

^     Ammon.  chloridi 3  JS3. 

Sod.  bromidi 3  iij. 

Tr.  opii.  camph fl.  3  ss. 

Aq.  menth.  pip q.  s.  ad  fl.  3  iij. 

M.  et  sig. :  Teaspoonful  every  three  or  four  hours. 

.387 


388  TREATISE    OX    NERVOUS    DISEASES 

For  dyspepsia  (nervous)  with  gastrectasia. 

J},     Tr.  nucis  vom A'  3  j. 

Sodii  bromidi 3  vj. 

Tr.  aurantii fl-  3  j. 

Tr.  gent,  comp q.  s.  ad  fl.  |  iij. 

M.  et  sig. :  Teaspoonful  a  half  hour  before  meals. 

Also 

1^     Ext.  chiratta  )  aa  gr.  xxiv. 

Ext.  gentian   ) 
M.  et  ft.  capsule  Xo.  xxiv. 
Sig. :  One  a  half  hour  before  meals. 

Also 

1^     Tr.  nucis  vom fl.  3  iv. 

Sod.  bicarb 3  jss.^ 

Inf.  gent,  comp q.  s.  ad.  fl.  3  iij. 

M.  et  sig. :  Teaspoonful  before  meals. 

For  nervous  syphilis. 

IJ     Hydrarg.  chlor.  corrosive gr.  j . 

Potass,  iodidi fl.  3  ij. 

Aquae  ciunamonii q.  s.  ad  fl.  |  iij. 

M.  et  sig. :  Teaspoonful  after  meals. 

Nervous  syphilis  (tonic  in). 

l)t     Tr.  nucis  vom 3  ij. 

Elix.  calisay^ q.  s.  ad  3  iij. 

M.  et  sig.  :  Dessertspoonful  every  three  hours. 

For  hysteria. 

^     Pil.  asafoetida gr.  iij. 

Sig. :  One  three  or  four  times  a  day. 

Hysteria  and  anaemia. 

r  Ext.  sumbul gr.  j. 

I  Ferri  sulph.  exsic gr.  j. 

^     Pil.  sumbul  comp.  ^  ^^^^ ^^ida gr.  ij. 

I  Acid,  arseniosi gr.  ■^• 

M.  et  ft.  pil. 

Sig. :  One  three  or  four  times  a  day. 


FOEMULARY  389 

Headache  (simple). 

5     Acetanilid , gi'-  ij- 

Camphor  monobrom gr.  ss. 

CafEeiue  citratis gr.  ss. 

M.  et  ft.  pil.  :N"o.  i. 

Sig. :  One  pill  every  three  hours  until  four  doses  if  required. 

Headache  (alcoholism). 

5     Tr.  nucis  vom,  )  ._   „      . 

ir,  •  •         r ^a  u..  3  !• 

Tr.  caprici         )  "^ 

Sod.  bromidi 3  ss. 

Tr.  gent,  comp q.  s.  ad  fl.  3  iij. 

M.  et  sig. :  Teaspoonful  every  three  hours. 

For  headache  (la  grippe). 
5     Salol 


T-,,  ,  •       i    ^3i  3  ss. 

rhenacetme 

M.  et  ft.  cap.  No.  xii. 

Sig. :  One  capsule  every  two  or  three  Hours  for  three  doses. 

For  headache  (cerebral  congestion  and  uricacidsemia). 

I^     Sod.  salicylat 3  iij. 

Codeine  sulph gi*-  v. 

Elix.  calisay^ fl-  o  j- 

Aquae q.  s.  ad  fl.  |  iij. 

M.  et  sig. :  Teaspoonful  every  four  hours. 

For  mental  depression  (bilious  temperament). 

I^     Acid,  nitrohydrochlor.  dil fl.  3  ijss. 

Tr.  nucis  vom fl.  3  iij. 

Tr.  aurantii q.  s. 

Tr.  gent,  comp q.  s.  ad  fl.  3  vj. 

M.  et  sig. :  Teaspoonful  a  half  hour  before  meals. 

For  pariEsthesia. 

^     Ext.  cascara  sagrada  fld fl- 1  ]• 

Ext.  ergot  fld |  Ij. 

M.  et  sig. :  Teaspoonful  twice  daily. 

For  Stokes-Adams  syndrome. 

^     Nitroglycerine gr.  3^. 

M.  et  ft.  pil. 

Sig. :  One  once  or  twice  daily. 


390  TREATISE    01s    XERVOUS    DISEASES 


Stomach  (irritability  and  acidity). 

IJ     Sod.  chlor 3  ij- 

Sod.  plios 3  iv. 

Sod.  sulph 3  5. 

M.  et  sig. :  Teaspoonful  in  seltzer  twice  daily  an  hour  before 
eating. 

General  tonic  in  simple  neurasthenia. 

5     Strych.  sulph gr.  -j-fg. 

Ferri  sulph gr-  I- 

Quin.  sulph gr-  J* 

M.  et  ft.  elixir q.  s.  ad  fl.  3  j- 

Sig. :  Teaspoonful  after  meals. 


INDEX 


Acromegaly,  symptoms,   331. 

diagnosis,    331. 

patliology,    331. 

prognosis,  333. 
Action,  reflex,  2.3. 
Adiposis  dolorosa,  324. 

diagnosis,    325. 

pathology,  325. 

prognosis,  325. 

treatment,  325. 
Adjunct  medication,    109. 
^lilstliesiometer,  65. 
^Esthesodic,  26. 
Agenesis,    226. 
Ageusia,  73. 
Agraphia,  189. 
Ainhum,   330. 
Alcohol,   78. 

Alcoholic  Insanity,  358. 
Alcoholism    (see  Neuritis),   356. 

diagnosis,  355. 

drug  intoxication,  354. 
symptoms,   354. 

pathology  of  chronic  forms   of,  356. 

prognosis,  355. 

prognosis   of    chronic    forms,    356. 

symptoms,  355 

treatment,  355. 

treatment  of  chronic  forms  of,   356. 
Alexia,  192. 
Algesia,  56. 
Algometer,  68. 
Amaurosis,    70. 
Amblyopia,  70,   192. 
Amblyopic  tabes,  229. 
Amemia,  191. 

Amnesia,    articulative,    193. 
Ampere,  92. 
Amyelia,   225. 
Analgesia,  66. 
Anaemia,   25. 
Anatomy,  1. 
Anelectrotonus,   93. 
Anencephaly,  196. 
Ankle  clonus,  57. 
Anosmia,   72,    125. 
Anterior  commissure,   7. 
Anterior   poliomyelitis    acuta,    255. 

diagnosis,  256. 


Anterior    poliomyelitis    acuta,    pathol- 
ogy, 255. 

prognosis,  256. 

treatment,   256. 
Anterior  pyramid,  16. 
Antifebrine,   360. 
Antipyrine,  360. 
Aphasia,  examination  for,  194. 

receptive,  191. 

sensory,   191. 
Aphasia,   motor,   190. 

ataxic,  191. 

auditory,  191. 

visual,  191. 
Aphemia,  189. 
Apoplexy,  198-200. 

cause,  199. 

cerebral  haemorrhage,  198. 

chronic  state  of,  202. 

coma  in,  202. 

diagnosis,  205. 

embolic,   202-205. 

hyperpyrexia  in,  201. 

in  cardiac  disease,  207. 

nursing,  205. 

pathology,  204. 

prognosis,  205. 

signs  of  attack,  200. 

treatment,  205. 
Appendix,   369. 
Apraxia,  189,   191. 
Arachnoid,  22. 
Arbor  vitse,  20. 
Argyll-Robertson   pupil,   60,   72,   227. 

in  tabes,  231. 
Arthritic   deformans,   340. 
definition,   chronic,   337. 
diagnosis,  337. 
Arthropathy  in  tabes,  229. 
Articulative  amnsesia,  193. 

ataxia,   190, 
Artificial  salt  bath,  84. 
Ascending   degeneration,   9. 
Asteriognosis,    58-185. 
Asynergia  verbalis,   190. 
Ataxia,   paralytic  stage,  229. 

amblyopic  stage,  229. 
Ataxic  gait,  63. 
Athetosis,  68. 

391 


392 


TKEATISE   OS   XEKV0U8   JJlJSEASES 


Axioms,   98. 
Axis  cylinder,  4. 
Axone,  2. 


Beri-beri,   141. 
Biceps  jerls,  59. 
Bilious  temperament,  64. 
Bipolar  cells.  2. 
Blindness,  37. 
Blood-vessels,  4.j. 
Blood-vessels  in  brain.   4.5. 
Brain,   malformation  of,   19G. 
capsule  of,   19. 
compression,  195. 
disease,  symptomatology  of,  19."i. 
irritative  symptoms  of,  195. 
tumour.  209. 
diagnosis,  211. 
localization,  210. 
pathology,  211. 
prognosis,  212. 
symptoms  of,  210. 
treatment,  212. 
weight  of.  197. 
Brachial  neuritis,  101. 
prognosis,  162. 
treatment,   162. 
Brachial  plexus,    injury  of,   161. 
Brown-S^quard,  25,  55. 

paralysis,  5. 
Bulb,  188. 

Burdach  column,  13. 
nuclei  of,  18. 


Caisson  disease,  217. 

pathology,   217. 

prognosis,  217. 

symptoms,   217. 

treatment.    218. 
Canal,  double  central.  226. 
Capsule  of  brain,  19. 

function  of,  38. 
Catalepsy,  105. 
Cataphoresis,  93. 
Cathelectrolonus,    94. 
Cauda  equina.  5. 

compression  of,   241. 

diagnosis  of  disease  of,  241. 

disease  of,  241. 

Irritation.  241. 

symptomatology     of     disease     of. 
241. 

symptom  of  disease  of,  241. 
Causalgia.  65. 
Cause  of  sleep,  43. 
Central  canal,   7. 


Centre,  primary  optic,  187. 
automatic,  34. 
cardiac  accelerating,  35. 
cardiac  inhibitory,  35. 
detrusor,  37. 
inductive,  30. 
thermogenic,  38. 
Centres  in  medulla,  17. 
of  consciousness,  41. 
Centrum,   186. 
Cerebellar  ataxia,  240. 
pathology,  240. 
symptoms,  240. 
tottering,  33. 
treatment,   240. 
Cerebellum,   19. 
Cerebral   hemisphere,  39. 
functions  of,  39. 
localization,   183. 
neoplasm,  209. 
peduncles,  functions  of,  36. 
varieties  of,  209. 
Cerebrum,   20. 
Charcot's  artery,  28. 
douche,  84. 
Joint,  230. 
Chemical   stimuli.   26,  29. 
Cholesterin,  47. 
Chorea,  278. 

definition  of,  278. 
paralytic   symptoms,  278,  279. 
Chorea,  284. 

minor     (see     Sydexham's     Disease 

and   St.   Vitis's   DA>fCE;,   278. 
prognosis,   280-282. 
symptoms  of,  280-282. 
Circulatory  disturbances,   121. 
Clarke,   column  of,  9. 
Claw-hand,  213. 
diagnosis,  213. 
prognosis,  213. 
treatment,  215. 
Climatology  in  tabes,  233. 
in  nervous  diseases,  112. 
Coal-tar  product    intoxication,    2;i.'j. 
diagnosis,  360. 
progno.sis,   360. 
symptoms,  360. 
treatment,  360.  , 

Cocaine  habit,  359. 
prognosis,  359. 
treatment,  359-360. 
Cold  packs,  84. 
Coma,  54. 

Combined  sclerosis.  260. 
diagnosis,  262. 
prognosis,  262. 
symptoms,  260. 
treatment,  260. 
types,  260. 


INDEX 


393 


Combined  sclerosis,   types  of  Putuam- 

Leichtheim-Dana,  260. 
Comma  tract,  14. 
Conjugate   deviation   of   tlie   eyes,    40, 

68,  202. 
Contractures,  66. 
Convalescence    of    nervous    functional 

diseases,   107. 
Convolutions,   21. 

ascending  frontal,   185. 

central,  183. 

parietal,    185. 

first  frontal,   185. 

second  frontal,  185. 

Convulsions,  clonic,  53. 

tonic,   53,    66. 
Convulsive  (Tic),  268,  288. 
diagnosis,  287. 
prognosis,  287. 
Co-ordinating  centres,   33. 
Corpora  quadrigemina,  22,  187. 

functions  of,  16,  30. 
Corpus   callosum,   186. 
striatum,  22,   186. 

functions  of,  367. 
dentatum,  20. 
Cretinism,   61. 
Crossed  pyramidal  tracts,  13. 

hemiplegia,  28. 
Crus  cerebri,   187. 
Cyclopia,  197. 


Dance,  86. 
Deafness,  72. 

psychic,   193. 
Decubitus,  64. 
Deep   reflexes,    57,    73. 
Degeneration,  15,  49. 
Degenerative  reaction,  94,  97. 
Dementia  paralyticus,   362. 
Dendron,  2. 
Dentate  nucleus,  16. 
Dermatosis  gangrenosa  nervosa,   327. 
pathogenesis,  328. 
prognosis,  328.  ' 

Descending  degeneration,  9. 
Detrusor   centre,    36. 
Diagnosis,  93. 
Diet,   79,  106. 

Diffuse     and    focal     diseases     of    the 
spinal  cord,  243. 
disease    of    brain    and    spinal    cord, 

267. 
disease   of   motor   neurons   of   cord, 
234. 
spinal-cord  functions,   240. 
Diplegia,  66. 

Direct  cerebellar  tract,   14. 
pyramidal  tract,  11,   14. 


Disassociatiou  of  sensation,  67. 
Diseases  of  brain,  195. 
membranes,  194. 
spinal   cord,  221. 
Diver's  disease,  217. 
Dizziness,  113. 
Drip  sheet,  85. 
Drugs,  24. 
Dura  mater,  22. 
Dyslexia,  194. 
Dyssesthesia,   65. 

Elbow-jerk,  59. 
Electrical  irritability,  93. 
Electricity,  faradic,  101. 

Franklin,  104. 

galvanic,  31. 

generation  of,  97. 

in  tabes,  233. 

sinusoidal,  100. 

static,  104. 
Electrolysis,  92. 
Electro-motor  force,  98. 
Electrotonus,  93. 
Embolism,  200. 
Encephalitis,   acute  symptoms  of,   207. 

causes  of,  207. 

chronic,  208. 

diagnosis,  208. 

pathology,   207. 

prognosis,  207. 

symptoms,  208. 

treatment,  208. 

varieties  of,  207. 
Encephalocele,  96. 
Erb,  electrical  reaction  of,  161. 
Erb's  symptoms,  357. 
Erythromelalgia,    76-142. 

histological   examination,   142. 
I'^xercise  in   nervous  diseases,   80. 

Facial  angle,  41. 
palsy,    129. 

diagnosis,  326. 

galvanism  in,  131. 

hemiatrophy,    326. 

hemiatrophy,   326. 

intracranial,  129. 

intraosseous,  129. 

pathology,  326. 

potassium  iodide,  131. 

strychnine  in,   131. 

treatment,   130. 
Family  ataxia,   138. 

periodical  paralysis,  343. 

symptomatology  of,  344. 
Faradic  electricity,   100-101. 

brush,  104. 
Fasciculus  of  Tuerck,  11. 
Fechner's  law,  43. 


394 


TREATISE   ON  XERVOUS   DISEASES 


Festination,    63. 
Filum  terminale,  5. 
Fissure  of  Rolando,  39. 
location  of,  39. 
median,    7. 
Fissures  of  cerebellum,  39. 
Flechsig,   9,   11,   21. 
Franklin  electricity,  104. 
Frazier   (C.  H.),  340. 
Friction,   86. 

Friedricli's    ataxia    (see    Hbkeditaet 
Ataxia),  238. 
diagnosis,  239. 
prognosis,  238. 
symptoms,    238. 
treatment,    239-240. 
Frontal  convolutions,  18-5. 
Forced  movements,  37. 
Formatio  reticularis,  16. 
Forms  of  disease,  49. 
Funiculi,  89. 

cuneatus,  16,  17. 
gracilis,   5. 

medulla  oblongata,  34. 
Rolando,  17. 

Gait,  61,   62. 
Galton's  whistle,  72. 
Galvanic  current,  31. 
Gangrene,  29. 
Gastralgia,   120. 

General  functional  nerve  disease,  277. 
paralysis  of  insane,  362. 
paresis,  362. 
Generally  nervous,  79. 
Geniculate  bodies,  22. 
Genito-urinary,   60. 
Gerlacb's  bodie.s. 
Giddiness,  113. 

Giles  de   la   Tourette's  disease,  286. 
Girdle  pain,  170,  227. 

sensation,   227. 
Glandular  defects,  49. 
Glassblower's  disease.  319. 

aetiology,  319. 

definition,  319. 

pathology,   319. 
Glia  cells,  46. 
Gliosis,    51. 
Glosso-labio-pharyngeal  palsy,  257. 

acute  form,  258. 

asthenic  form,  258. 

chronic,  258. 

pathology,  257. 

prognosis,  258. 

pseudo  form,  257. 

symptoms,  257. 

treatment,   258. 
Goll,  14. 
Gowers,  11. 


Grasp,  63. 

Graves's  disease,  electricity  in,  97. 
Guide  to  note-taking,  55. 
Gyrus  fornicatus,  211. 
tumour  in,  211. 

Habit  chorea,  283. 
diagnosis,  284. 
pathology,  284. 
prognosis,  283. 
symptoms,  283. 
treatment,   284. 
Hsematoma  dura,  175. 
diagnosis,  175. 
prognosis,  175. 
symptoms,   175. 
treatment,   176. 
Hsematomyelia,  245-247. 
diagnosis,  246. 
pathology,  246. 
prognosis,   247. 
symptoms,   246. 
treatment,  247. 
Haemorrhage     in    substance    of    cord, 
245. 
aetiology,   245. 
Hair,  removal  of,   97. 
Hallucinations,  45. 
Hammer-toe,  166. 
Hammond,  Dr.,   68. 
Headache,  120. 
causes  of,  121. 
varieties  of,  121. 
Hearing,  72. 

Heart,  neuralgia  of,  120. 
Heat  exhaustion,   340. 

prognosis,    341. 
Hemianopsia,  55,   69,  70,  192. 
Hemiopia,  70. 

Hemiplegia,  15,  39,  196,  204. 
gait  in,  202. 
in  neuritis,  204. 
secondary  contraction  In,  204. 
sweating  in,  195. 
Hereditary    ataxia     (see    Feeidrich's 

Ataxia),  238. 
Hereditary  spastic  paralysis,  238. 
chorea,  284,  286. 
diagnosis,   285. 
duration,    285. 
Hernia,  197. 

Herpes  zoster  in  Pott's  disease,  163. 
Heteropia.  225. 
High  flushing  of  colon,  110. 
Hippocampal  convolution,   18. 
Hippus,  71. 

Hoffman   symptoms,    357. 
Holtzapple.  Dr.,  343. 
Huntingdon's  disease  (see  Herbditakt 
Chorea),  284. 


INDEX 


395 


Hydrencephalocele,  196-198. 
Hydrocephalic  cry,  178. 
Hydrocephalus,  177. 
acquired  forms,   180. 
acute  symptoms,  177. 
chronic,   179. 
external,   177. 
internal,  177. 
pathology,  176. 
prognosis,  178. 
symptoms,  179. 
treatment,  179. 
Hydromyelia,  212. 
symptoms,  213. 
Hydrophobia   (see   Rabies),   346-347. 
Hydrorhachis  interna,  223. 
Hydrotherapeutics     in     nervous     dis- 
eases, 81. 
Hygiene,  78. 
Hypersemia,  49. 
Hypersesthesia,  53,  65. 
Hyperageusia,  73. 
Hyperosmia,  72,  125. 
Hyperostosis    cranii    (cephalomegaly), 
322-323. 
diagnosis,    323. 
pathology,   324. 
symptoms,  323-324. 
Hypertrophic    pulmonary    arthropathy, 
334. 
pathology,   334. 
treatment,  334. 
Hypnotics,  43. 
Hypnotism,    104,   105. 

in  tabes,  229. 
Hyposesthesia,  53,  65. 
Hysteria,  302. 
aetiology,   302. 
definition,   302. 
diagnosis,   304. 

Gowers'    differential  table,    302-303. 
grand  attacks  in,  304. 
hypnotics  in,  305. 
passionate  attitudes  in,  304. 
prognosis,  305. 
psycho-sensory,   302. 
segmental  anaesthesia,  303. 
catalepsy,    304. 
motor  symptoms,  304. 
paroxysmal   stage,  304. 
stigmata,  303. 

divisions  and  symptoms,  308. 
pathology,  312. 
rigidity  of  back,  309. 
tender  spots,  309. 
traumatic  or  railway  spine,   308. 
treatment,  312. 
symptoms,  302. 
treatment,  305. 
Hysterical  or  hystogenic  zones,  303. 


Ideation,   45,   193. 

Idiopathic  muscular  atrophy,  252. 

juvenile,   254. 

neurotic,  254. 

pathology,   254. 

treatment,  255. 
Illusion,  45. 

Incisures   Lantermann,   4. 
Inductive   centres,   30. 
Inflammation,   24,  50. 
Inhibition,   24. 
Insomnia   and  causes,   115. 
pathology,  116. 
treatment,    116. 
Interfascicular   arcades,    46. 
Interpeduncular   space,   119. 
Irritability  of  nerves,  29. 
Irritable   spine,   221. 
Irritative   lesions,    184. 
Isolation    in    nervous    diseases,    106. 

Jacksonian  cerebral  epilepsy,  40. 
Jacobson's   nerve,    132. 
Jaw-jerk,  59. 
Jumper's   disease,    287. 
Jumping  disease,  288. 

diagnosis,    288. 

pathology,   288. 

prognosis,  288. 

saltatory  spasm,  288. 

treatment,  288. 


Kakke,  142. 
Kernig's  sign,  173. 
Krause,   47. 


Labile  current,  99. 
Landry's  paralysis,  218. 
diagnosis,  219. 
pathology,  219. 
prognosis,  219. 
treatment,  219. 
Lateral  column,  11. 

fillet,  18. 
Lantermann's  incisure,  5. 
Lead,  mercury,  and  arsenic  poisoning, 

357-358. 
Lecithin,  33. 

Leptomeningitis,  171,  212,  215. 
cerebral,  177. 
prognosis,   177. 
symptoms,  177. 
treatment,  177. 
symptoms,   215. 
Lesions,   destructive,   184. 

in  diseases  of  cauda  equina,  242. 
irritative,  184. 
of  lower  end  of  cord,  241. 


396 


TEEATLSE    O^   XEKVOUS   DISEASES 


Lesions  of  peripheral  nerves,  242. 
Lethargy  in  hypnotism,  105. 
Lissauer's  tract,  15. 
Localization,    ascending  frontal,    184. 
parietal,  185. 

central  convolutions,   185. 

cerebral,  183. 

corpus  callosum,   186. 

cuneus,  185. 

frontal  convolutions,   185. 

internal   capsule,    187. 

occipital,  183. 

precentral  lobe,  185. 

superior  parietal  lobe,  183. 

temporal  lobe,  183. 

visual,  191. 
Lockjaw,  347. 

aetiology,   347. 

symptomatology,   347. 

treatment,  347. 
Luetic  infection,  78. 
Lumbago,  162. 
Lymphatic  temperament.  63. 


Malformations,  49. 

of  brain,  196. 

of  spinal  cord,  221. 
Marie,   types   of  family  ataxia,  238. 
Martinotti,  cells  of,  21. 
Massage,  85. 

contraindications,  89. 
Mattson's  thermometer,  77. 
Mechanical  stimuli,  29. 
Medication,  109. 
Medulla  oblongata,  15,  188. 

reflex  action,  34. 
Megrim,  121. 
Meningitis  serosa,  182. 

chronic,  174. 
diagnosis,  174. 
prognosis,   174. 
symptoms,    174. 
treatment,  174. 

internal,  212. 

hypertrophic,    213. 

treatment,  183. 
ileningocele,  acquired,  198. 

congenital,   198. 

of  cord,  224. 

pathology,  198. 

prognosis,  224. 

symptoms,   224. 

treatment,  198,  224, 
Metatarsalgia,  166. 
Micrencephaly,  196. 
Microcephaly,  196. 
Migraine.   121,   122. 
Milliampgre,  92. 
Mind  blindness,  191. 


Mitchell,  J.  K.,  Jr.  88. 
Mitchell,  J.  K.,  St.,  384. 

S.  Weir,  58,  86,  279. 
Mixed  diet,   78. 

nerves,  29. 
Monoplegia,  15,  28,  66. 
Morton's  disease,  166. 

fluid,  224. 
Motor  centres,   15. 

decussation,   15. 

nerves,  7. 

tract,  19. 
Multiple  neuritis,  267. 
aetiology,  267. 
(beri-beri),   141. 
diagnosis,   268. 
prognosis,  268. 
symptoms,    267. 
treatment,   269. 
Multipolar  cells,  2. 
Muscle  centres,  31. 
Muscle  sense,  56. 
Muscular  dystrophics,  2.50. 

movements,   89. 

sensibility,  68. 
Myelitis  (see  Ixflamsiatiox  of  Sprs-tT. 
CoRD),  262. 

causes,  263. 

diagnosis,  264. 

pathology,   263. 

prognosis,   264. 

symptomatology.  263. 

treatment,  264. 
Myelin  sheath,  9. 
Myelocele  syringo,  223. 
Myotoni  congenita,  94. 
Myxoedema,  61. 


Narcotics,  78. 
Nerve,  abducens,  128. 

causes  of,   128-129. 

paralysis  of,   128. 
afferent,  231. 
anterior  crural,  164-165. 

prognosis,   165. 

symptoms  of  diseases  of,  165. 

treatment,   165. 
arrangement  of  fibre,  5. 
ascending  frontal,  185. 
auditory,   131. 

disease  of,  131. 

localization   of,  191. 
cells,  1. 
centres,  1,  5. 
eervico-occipital,  153. 

cause  of,  153. 

neuralgia  of,  153. 

prognosis,    153. 

treatment,  153. 


INDEX 


39? 


Xerve,   circumflex,  153. 

disease  of,  153. 

distribution  of,"  153. 

origin  of,   153. 

paralysis  of,  153. 

prognosis,  154. 
cranial,    disease  of,   125. 
external  cutaneous    anterior  crural, 
164. 

plantar,   166. 

popliteal,    160. 
facial,   129. 

degeneration  of,  129. 
fibre,  1-4. 

functions  of,  28. 
glossopharyngeal,   132. 

disease  of,  132. 

interosseous,   132. 
great  sciatic,  165. 

sensory  symptoms,  166. 

symptoms  of  disease  of,  165. 
hypoglossal,   nerve,  1.33. 

cause  of,  1.34. 

centres  of,  133. 

disease  of,  134. 

symptoms,   1.34. 

treatment,  134. 
intercostal,  neuralgia  of,  118. 

prognosis  of,  118. 
internal  plantar,  166. 

popliteal.    166. 
median,  157. 
musculo-spiral,    154. 

disease  of,  154. 

distribution  of,  154. 

prognosis,  154. 
Nerves  of  lower  extremities,  16.3. 

trunk,   163. 
obturator,    165. 
patheticus,  128. 
peripheral,  1.35. 

disease  of,  135. 

recurrent,  132. 
peroneal,  166. 
pneumogastric,   133. 

recurrent,  133. 
spinal  accessory,  133. 

disease  of,  133. 
superior  gluteal,   165. 

centre,  128. 

tissue,  47. 

trifacial,  128. 
trunks,  163. 
tumours,   148. 

false  neuroma,  148. 

hyperplasia,  149. 

malignant,  148. 

true  neuroma,  148. 
ulnar,   156. 
vaso-oonstrictor,   27. 


Nervous  diseases,  cause  of,  77. 

endarderitis  obliterans,  278. 

gummata,  273. 

gummatous  meningitis,   273. 

syphilis,    diseases    of    blood-vessels, 
272. 

temperament,    64. 
Neuralgia,  117. 

anterior  crural,  119. 

cervico-occipital,  1.53. 

facial,  153. 

of    heart    (and    pseudo    angina,    see 
Hysteeiaj,   302. 

parasthetic,  163. 

sciatic,  118. 

visual,   129. 
Neurasthenia,   298. 

causes  of,  29-5-296. 

definition,  295. 

diagnosis,  298. 

pathology,    298. 

primary,  298. 

prognosis,  298. 

relation  of  genital  organs  to,  296. 

secondary,  298. 

symptoms,  296. 
sensory,  297. 

vaso-motor,  297. 
Neuraxon,   2. 
Neuritis,   arsenical.   141. 

aetiology,  139. 

atrophy  in.  137,  147. 

chronic,  137. 

deformity  in,  144. 

diagnosis,   141. 

diphtheria,   140. 

interstitial,  136. 

lead,  140. 

leprous,  143. 

local,  136. 

multiple,  136,  138,  139. 

obturator,  141. 

oculomotor,  127. 
palsy,  127. 

olfactory,  125. 

parenchymatous,  138. 

pneumogastric,    133. 

prognosis,  138. 

reaction  of  degeneration  in,   136. 

reflexes  in,  138. 

special,  139. 

subacute,  137. 

symptoms,  137. 
Neurilemma,   2. 

Neuro-bilious  temperament,  64. 
Neuroglia,  46. 
Neuron,  2,  74. 

Nodal  change  in  muscle,  94. 
Nodes,   Ranvier,   4. 
I    Nuclei  of  Burdach  and  Goll,  18. 


398 


TKEATISE   OX    NERVOUS   DISEASES 


Nucleus  ruber,  2,  18. 

emboliforiuis,  20. 

fastigii,   20. 

glabosus,  20. 
Nystagmus,  37,   69. 


Object  blindness,  191. 
Occipital  lobe,  183. 
Occupation  neurosis,  .313. 

causes,  313. 

definition,  313. 

muscular  cases,  313. 

prognosis,    314-315. 

treatment,   315. 

vascular  cases,  313-314. 
Ocular  disturbances,  69. 
Q'Mema,  49. 
Ohm,  49. 
Ohm's  law,  92. 
Olivary  body,  14. 
Ophthalmoplegia   externa,   127. 

interna,  127. 
Opium   poisoning,   symptoms  of  acut< 
358. 

prognosis  of  acute,  3.58. 

symptoms  of  chronic,  358. 

treatment  of  acute,  .3.58. 
Optic  atrophy  in  tal)es,  228. 
thalamus,  18,  21,  186. 


Pachymeningitis  spinal,  212. 

cerebral  acute,  172. 

cerebral    internal    hsemorrbagica. 
175. 

externa,  171,  212. 

hypertrophic,   215. 

interna,  212. 

prognosis.  173. 

symptoms.  212. 

treatment,  173. 
Paget's  disease,  3.33. 
Pantomime,  190. 
I'aracentral   lobule,   185. 
I'aradoxical  contraction,  59. 
Parfesthesia,  53,  65. 
Parresthetic  melalgia,  163. 
Parageusia,  73. 
Paragraphia,  19.3. 
Paralexia,  193. 

Paralysis       agitans       (see       Shakinu 
Palsy),  267. 

cause.   269. 

prognosis,    271. 

symptoms,   270. 

treatment,   271. 
Paralytic  stage  in  tabes,  229. 
Paramemia,  191,  193. 
Paraphasia,  194. 


'    Paraplegia,  66. 
Paresis,   alcoholic,  362,  370. 
alcoholic    p^<?"do-,    .362,    .370. 
hypochondriacal    type,   .366. 
syphilitic  pseudo-.   .3(!6. 
treatment,   370. 
Parturition    centre.    26. 
Patellar  reflex,  25. 
Pathological   gaits,   62. 
Pathology   of    nervous   system,    49. 
of    primary    ascending    lateral    .scle- 
rosis,  235. 
of  tabes,  231. 
Paths  of  spinal  cord,  26. 
Pegleg,   166. 

Perforating    ulcer    in    tabes,    229. 
Perineurium,  5. 
Pfliiger's   law,  24. 
Phenacetine,  use  of,  366. 
Physical  care  of  nervous  cases,  188. 
Physiognomy.  66. 
Pia   mater.   20,   22. 
Piersol.    Dr.,   4. 
Picsmeter,   68. 
Plantar   reflex,  25,  ."t7. 
Poisons,    24,    .50. 

Polioencephalitis,      chronic      superior, 
209. 
Inferior,  209. 
diagnosis.   209. 
prognosis,   209. 
treatment,  209. 
Pons  Varolii,   16,  17.   IRS. 
Pontine   lesions,    .56. 

nucleii,    17. 
Porencephal.v,    197. 
Post-hypnotic  suggestion,   106. 
Posterior   commissure,   7. 

spinal   sclerosis,  226. 
Pott's  disease,    16.3. 
Precocious  children,  78. 
Prefrontal  region.   186. 
Pressure  sense,   68. 
Primary  optic  atroph.v.  228. 
lateral  sclerosis,   2.3.5. 
diagnosis,  235. 
pathology  of,  2.35. 
treatment,    234. 
Prognosis    of    cerebrospinal    disease, 
and  treatment,  275. 
paralysis  in,  2.37. 
primar.v  lateral  sclerosis.  2.36. 
pseudohypertrophic    paralysis,    252. 
Propulsion,   63. 
Proteids,  33. 

Pseudo-bulbar   palsy,   2.59. 
treatment,   2.59. 
hypertrophic  paralysis,   2.52. 
reflex,   251. 
Psoas's  abscess,   163. 


mDEX 


399 


Psychic  deafness,  193. 
Psychoses,   53. 
Piu-kinje   cells,   20. 

Rabies    (see   Hydrophobia),   346. 
Reaction  of  degeneration,  94. 
Reflex  accommodations,   60. 

arc,  23. 

light,   60. 
Reflexes,   24,    25,    56,    126. 

abdominal,  25. 

ano-spinal,  26. 

bulbo  cavernosus,   75. 

cilio-spinal,  25. 

contra-lateral,    58. 

cremasteric,  25. 

cutaneous,   73. 

deep,  74. 

elbow,    58. 

epigastric,  25. 

genito-spinal,  26. 

genito-urinary,   94. 

infra-orbital,   57. 

irritative,    121. 

palmar,  57. 

parturition,   26. 

patellar,  25. 

plants,  25. 

scapular,   25. 

sweat  centres,  26. 

tendo-AchlUes,  59. 

vaso-motor,  25. 

vesico-spinal,   26. 

visceral,  73. 

wrist,  59. 
Regulation  of  galvanic  current,   98. 
Relay  station,    motor    sensory   nerves, 

33. 
Remak,   fibres  of,   5. 
Rest  treatment,  102,  106. 
Restiform  bodies,  16. 
Retropulsion.    63. 
Rheostat.  98. 

Rhizomelique  spondylitis.    168. 
aetiology,  168. 
girdle   sensation,    170. 
pains,    168. 
pathology,    168. 
prognosis,    170. 
symptoms,    168. 
treatment,    170. 
Risus  sardonieus,  348. 
Romberg,   228. 
Romberg's   sign,    61,   228. 

Salaam   convulsions,   312. 
Saltatory  spasm,  287. 
Sanguineous  temperament,  64. 
Scapular  reflex,  25. 


Schiff,  26. 

Schmidt  segments,  4. 
Schwann,  white  substance  of,  4. 
Sciatic   neuralgia,   119. 
neuritis,  162. 
double,  147. 
pelvic  disease,   147. 
Scleroderma,  329. 
circumscribed.    329. 
diffuse,  3.30. 
pathology,  330. 
Sclerosis,  49. 
Scottish  douche,   85. 
Secretory  phenomena,  64. 
Sensation  of  motion,  69. 
Sense  of  weight,  68. 
Sensorio-motor  region,  185. 
decussation,  28. 
nerve,  7. 
tracts,   19. 
Shower-baths  in  nervous  diseases,  83. 
Sinusoidal  current,  99. 
Smell.  72. 
Somnolence,  198. 

Somnolent  disorders  of  sleep,  372-373. 
Soul   blindness,    191. 
Spasm,    53,    63. 
Spastic  gait,  62. 

hemiplegic  gait,   62,   202. 
reflexes,  00. 
spinal    paralysis,    236. 
diagnosis,  237. 
prognosis,    238. 
•symptoms,    237. 
treatment,    238. 
Spina  bifida,  224. 
diagnosis,    224. 
prognosis,    224. 
treatment,    224. 
Spinal   accessory,    torticollis,    1.33. 
Spinal  cord,   5. 

asymmetry  of,  226. 
double  canal  of.   226. 
meningocele,    224. 
splitting    of,    226. 
hypersemia,  243. 
setiology,   243. 
chronic,    243. 
pathology,   243. 
symptoms,   243. 
treatment,  243. 
membranes,    inflammation    of,    212. 
meningeal   hfemorrhage,   244. 
aetiolog.v,    244. 
diagnosis,  244. 
prognosis,    245. 
treatment.    245. 
meningo-myelocele,   223. 
nerve,   disease  of,  151. 

destructive   symptoms   of,   151. 


■400 


TREATISE   OX  XERVOUS   DISEASES 


Spinal   nerve,    Irritative   symptoms   of, 
151. 
paralysis,   454. 
reflex,  23. 
Stabile   current,   98. 
Station,   Gl. 

Steam-baths  in  nervous  diseases,  84. 
Strabismus,   37. 
Strenfe'tli  of  stimuli,  4:i. 
Stupor.   .")3. 

Subjective  sensation,   45. 
Substantia  fielatino.sa  centralis,   7. 

lateralis,  7. 
Sudden  clianges  in  iiair,  .T20. 
pathology,  321. 
prognosis,    321. 
treatment,  321-.322. 
Sunstroke    (insolation,    thermic    fever, 
coup  de  soleil),  'M. 
prognosis,   .34. 
Suspension  (tabes).  2.3.3. 
Sway,  228. 
Sweat  centres.  20. 
Sylvius,  21,  4U. 

Sympathetic  system.  2S.   I.3.S. 
Symptoms,  of  cerebral  syphilis,  273. 
of  primary  lateral   sclerosis.  2;{4. 
(if  spinjil  paral.v.sls,  2.37. 
of  spinal    syphilis,   274. 

diagnosis,    275. 
syringomyelia,   248-249. 
treatment,  247-248. 
Syphilis  in  nervous  diseases,  272,   ,3,31. 
Syringomyelia.  223. 


Tabes,  232. 

causes,  231. 

diagnosis,   231. 

dorsalis,   226. 

duration,  231. 

pathology,  231. 

prognosis,   232. 

stages  of,  22G. 

treatment.  231-2.34. 
Tapotement,  87. 
Tastes,   72. 

Tea  and  coffee  poisoning,  357. 
Tegmentum,    17,   188. 
Temperament,   63. 

bilious,  64. 

lymphatic,   63. 

neuro-bilious,  64. 

sanguineous,  64. 
Temperament,  76. 

in  erythromelalgia,   76. 

sense,  56. 
Temporal  lobe,   1S6. 
Tetanilla   (see   Tetaxy).  350. 
Tetanus  (see  Lockjaw),  350. 


Tetany,  350. 
aetiology,  350. 
diagnosis,  352. 
symptoms,  350. 
treatment,   353. 
Thermal  stimuli,  29. 
Thomsen's  disease,  288. 
diagnosis,   28.8. 
pathology,  288. 
treatment.    288. 
Thrombosis,  89. 
Tic,   convulsive,   08. 
douloureux,  53,  117. 
diagnosis,    118. 
pathology,    118. 
prognosis,    118. 
symptoms,   117. 
treatment,   118. 
Titubating  gait.  0.3. 

Tract,    ascending   degeneration   of,    14. 
descending,   13. 
differentiation  of,  9. 
direct  cerebellar,    14. 
Transmission  of   nerve  symptoms,   32, 
Traumatic  hysteria.   311. 
pathology,  311. 
prognosis,   311. 
treatment,  312. 
Treatment  of  nervous  disorders,  77. 
of  primary  lateral  ascending  sclero- 
sis, 230. 
of  spinal  paralysis.  2.37. 
Tremors.  (IS,  286. 
Trophlf  centres,  27. 
disturbances,    00. 
Tntusseau's   sign,   351. 
Tuberculosis.   49. 
Tuerck.   11. 
Turkish  bath.  82. 
bathing.    81. 


Unipolar   cells,   2. 

I'se  of  electricity.   102. 


Vasoconstrictor  nerves,  27. 
Vaso-motor  nerves.  27.  36. 

centre,  27,  36. 

disturbances,  60. 
Ventricles  of  brain,  221. 
Verbal  amnesia,  198. 
Vermiform  process.  19. 
Vermis.  188. 
Vertigo,  113. 

causes,   113. 

diagnosis.    113. 

prognosis,  114. 

symptoms,  114. 

treatment,   114. 
Vesicospinal  centre,  20. 


INDEX 


401 


Visceral  neuralgia,  120. 

reflex,  60,   75, 
Visual  centre,  41. 
Volt,  92. 
Voluntary  inhibition,  24. 

Waldeyer,   2. 

Wallerian  method,  9. 

Water  as  a  tonic,  84. 

Weber  and  Fechner's  law,  43. 


Weber,   law  of,  43. 
Wernicke,   70. 
Wernicke's      hemiopic 

action,    sign,   70. 
Whistle,    Galton's,    72. 
Woorara,  29. 
Wrist  reflexes,   29. 


Zappert,  362. 


pupillary      in- 


(1) 


26 


DISEASES  OF  THE  HEART 
AND  ARTERIAL  SYSTEM 

By  ROBERT  H.  BABCOCK,  A.M.,  M.D. 

Professor   of  Clinical    Medicine   and    Diseases   of  the    Chest,    College    of    Physicians 

and    Surgeons    (Medical    Department   of   the    lUinois   State    University), 

Chicago  ;    Attending    Physician   to  Cook   County   Hospital   for 

Consumptives  ;  Fellow  and  former  President  of  the 

American  Climatologica!  Association,  etc. 

Three   Colored    Plates   and   One    Hundred   and   Thirty-nine 
illustrations  in  the  Text.      8vo.      Cloth,  $6.00 

SOLD     ONLY    BY    SUBSCRITTION 

"  This  treatise  is  evidently  the  result,  not  only  of  large  clinical  experience,  but  of 
wide  reading  and  careful  reflection.  The  author  disclaims  any  pretense  of  originality, 
but  it  is  open  to  question  whether  the  conclusions  and  results  of  a  ripe  judgment,  such 
as  are  presented  in  this  volume,  are  not  worth  quite  as  much  as  some  academic  so- 
called  original  work.  Certainly  a  large  amount  of  material,  both  clinical  and  literary, 
has  been  worked  out  and  presented  in  a  most  clear,  succinci,  and  practical  manner. 
The  author's  style  is  pleasing  and  without  ambiguity,  nor  is  the  text  over-loaded  with 
unnecessary  technical  terms.  Alter  a  careful  perusal  of  Dr.  Babcock's  book  there  are 
two  features  which  strike  the  reader  as  char.acteristic  and  valuable.  These  are,  on 
the  one  hand,  the  case  histories,  and,  on  the  other,  the  unusu.il  r.umber  and  value  of 
the  pages  devoted  to  tiie  therapeutics  of  the  subject.  The  narration  of  cases,  although 
at  times  in  much  detail,  does  not  cause  the  usual  weariness  of  flesh  in  the  reading, 
mainly  because  of  the  interesting  manner  in  which  they  are  written.  They  are 
particularly  well  chosen  to  illustrate  the  manifold  varieties  of  disease  and  the  practical 
wisdom  required  in  the  management  of  actual  cases.  Regarding  the  therapeutic  side 
of  the  work  none  but  words  of  praise  are  required.  So  far  as  the  reviewer's  reading 
goes  there  is  no  more  complete  and  reliable  exposition  of  the  treatment  of  circulatory 
disease  than  that  found  in  this  volume.  That  this  high  commendation  is  deserved  will 
readily  be  admitted  after  reading  chapters  i6,  17,  and  18  upon  the  treatment  of  valvular 
heart  disease.  These  chapters  are  distinguished  by  a  fulness  of  detail  and  a  variety  ot 
therapeutic  resource  which  cannot  but  prove  of  great  value,  not  only  to  the  young 
practitioner,  but,  as  well,  to  the  clinician  of  years. 

"The  book  can  be  unhesitatingly  recommended  as  a  distinct  acquisition  to  one's 
working  library." — "Brooklyn  Medical  Journal. 

"We  commend  to  our  readers  this  work  of  Babcock's  as  a  very  desirable  work 
for  both  the  specialist  and  the  practitioner,  and  wish  the  author  a  most  hearty  wel- 
come for  his  admirable  literary  endeavor. "-^Medical  News. 

D  .     A  P  P  L  E  T  O  N     AND     COMPANY,     NEW     YORK. 


A  TREATISE  ON 
MENTAL  DISEASES 


Bv  HENRY  J.   BERKLEY,  M.  D. 

Clinical   Professor  of   Psychiatry,  Johns   Hopkins   University 
Chief  Visiting  Physician  to  the  City  Insane  Asylum,  Baltimore 


With    15   full-page  Lithographic   Plates  and  57  Text 
Illustrations.    624  pages.     8vo.     Cloth,  S5.00 


"This  work  should  be  in  the  hands  of  every  physician,  as  it  is  one  of  the  clearest  and  mo>t 
comprehensive  works  written  on  the  subject  of  mental  diseases  that  is  available  to  the  general 
practitioner."— //i/^r-.S/a/f  Medical  Journal,  St.  Louis,  Mo. 

"  This  is  a  valuable  book  to  the  student  of  psychiatry,  and  will  entertain  and  instruct  the 
neurologist  and  the  general  practitioner.  It  will  also  enlighten  our  legal  brethren,  who  so 
often  aim  to  make  it  appear  that  insanity  is  not  disease,  and  that  experts  on  mental  alienation 
know  little  more  than  themselves  of  the  subject." — Alienist  and  Xeurologist,  New  York  City. 

"The  medical  profession  is  to  be  congratulated  that  a  comprehensive,  practical  work  on 
mental  diseases  in  English  has  at  last  in  this  book  been  presented  to  them.  To  the  general 
practitioner,  who  is  usually  the  first  to  see  and  treat  the  patient  suffering  from  mental  disorder, 
as  well  as  to  the  alienist,  this  work  will  prove  very  s^wUcAt."— Journal  0/  Nervous  and 
Mental  Diseases. 

"  A  worthy  product  of  the  scholarly  atmosphere  of  the  Johns  Hopkins  University  is  this 
latest  volume  in  the  field  of  psychiatrj'  by  Professor  Berkley,  dedicated  to  Prof.  Henry  M. 
Hurd,  so  well  known  in  Michigan.  It  goes  further  and  does  more  than  any  text -book  which 
we  Lave  to  clearly  set  forth  the  pathological  basis  of  the  insanities  and  its  immense  import- 
ance."— Medical  Age,  Detroit,  Mich. 

"  The  practical  character  of  this  work  is  ampl^'  evidenced  in  the  selection  of  illustrations 
which,  though  few,  are  of  the  best.  The  subject-matter  is  arranged  in  logical  sequence,  and 
each  chapter  is  in  itself  a  comprehensive  treatise.  Full  scof>e  is  given  in  the  discussion  of  the 
elemental  brain  and  nerve  structure  before  the  types  of  disease  are  considered.  While  each 
chapter  deserves  especial  notice,  the  more  notable  are  those  on  the  Psj'choses  of  Old  Age,  the 
Psychoses  of  Childhood,  the  Insanities  of  the  Puerperal  Period,  Neurasthenia,  and  those 
dealing  with  the  pathology  of  mental  diseases.  The  publishers  have  spared  nothing  in  the 
making  of  the  book." — New  Orleans  Medical  and  Surgical  Journal. 

D.  APPLETON    AND    COMPANY,   NEW  YORK 


PRACTICAL  DIETETICS, 

WITH  SPECIAL   REFEREXCE   TO  DIET  IS  DISEASE. 
By  AV.  GILMAX  THOMPSOX,  M.D., 

Professor  of  Medicine  in  the  Cornell  Medical  College  of  the  City  of  New  York;  Visiting 
Physician  to  the  I'resbyleriun  and  Belkvue  Hospitals,  New  York. 

LARGE  OCTAVO,  EIGHT  HUNDRED  AND  FOURTEEN  PAGES, 

ILLUSTRATED. 

Cloth,  $5.00. 

SECOND   REVISED   EDITION.     SOLD   ONLY   BY  SUBSCRIPTION. 


"  This  is  at  once  the  best  and  most  exhaustive  book  upon  this  sub- 
ject with  which  we  are  familiar.  The  best,  because,  in  the  first  place, 
it  is  written  by  a  teacher  of  thora])eutics  who  knows  the  needs  of  the 
practicing  physician,  and  yet  who  has  taught  in  previous  years  as  a 
professor  of  physiology  all  that  one  needs  to  know  in  regard  to  the 
principles  of  digestion  and  assimilation.  For  tliis  reason  the  author  is 
unusually  well  qualified  to  prepare  a  useful  manual,  but  it  is  not  until 
one  has  perused  the  vohime  that  he  thoroughly  grasps  the  scope  and 
depth  of  the  manner  in  which  Dr.  Thompson  has  treated  his  subject." 
—  Therapeutic  Gazette. 

''  The  subject  of  the  dietetic  treatment  of  disease  is  not  an  attractive 
one.  This  fact  explains,  no  doubt,  the  comparatively  little  attention 
given  it  in  college  curriculum  and  daily  study.  When  one  proceeds  to 
examine  the  valuable  contributions  to  this  subject,  the  scientific  inves- 
tigations which  have  been  made  by  the  United  States  Department  of 
Agriculture  at  various  experiment  stations  in  all  parts  of  the  countr5\ 
he  is  convinced  that  it  is  high  time  to  look  into  the  matter  pretty  thor- 
oughly. This  book  is  of  value  for  its  summary  of  the  latter  and  its 
application  of  the  knowledge  to  the  treatment  of  the  disease." — 
Brooklyn  Medical  Journal. 

"Diet  in  disease  is  most  expansively  considered,  and  complete  and 
reliable  dietaries  for  every  ailment  are  suggested.  The  dietetic  errors 
responsible  for  a  large  number  of  diseases  are  also  fully  discussed. 
Altogether,  it  is  perhaps  the  best  work  extant  upon  the  subject  of 
dietetics." — Hahnemannian  Monthly. 

"A  good  book  and  a  practical  one." — Canadian  Practitioner  and 
Review. 

"In  the  seven  years  which  have  elapsed  since  the  first  appearance 
of  this  standard  text-book  there  have  not  been  the  many  and  important 
changes  in  dietetics  that  other  departments  of  our  therapeutics  have 
xmdergone.  Xevertheless,  Dr.  Thompson  has  revised  much  that  was 
published  in  the  first  edition,  and  has  introduced  into  this  one  the  re- 
sults of  more  recent  studies  iu  the  economic  values  of  various  dietaries. 
The  general  arrangement  of  the  work  is  unchanged." — S'eio  York 
Medical  Journcd. 

D.  APPLETOX   AXD    C03IPAXY,  XEW   YORK. 


THE  SURGICAL  DISEASES 

OF   THE   GENITO-URINARY 

ORGANS. 

By  E.  L.  KEYES,  A.  M.,  M.  D.,  LL  D., 

Consulting  Surgeon  to  the  Bellevue  and  the  Skin  and  Cancer  Hospitals  ;    Surgeon  to 

St.  Elizabeth   Hospital ;    formerly  Professor  of   Genito-Urinary  Surgery, 

Syphilology,  and    Dermatology  at   the    Bellevue    Hospital 

Medical  College,  etc.  ;    and 

E.  L.  KEYES,  Jr.,  A.  B.,  M.  D.,  Ph.D., 

Lecturer  on  Genito-Urinary  Surgery,  New  York  Polyclinic  Medical  School  and  Hospital ; 

Assistant  Visiting  Surgeon  to  St.  Vincent  s   Hospital  ;    Physician  to  the 

Venereal  Clinic,  Out-Patient   Department  of  the  House  of 

Relief  of  the  New  York  Hospital,  etc. 

Cloth,  $5.00:   halt"  leather,  $s.5o. 

Sohi  only  by  Subscription. 

WITH    ONE    HUNDRED    AND    SEVENTY-FOUR    ILLUSTRATIONS    IN    THE    TEXT 
AND   ELEVEN    PLATES,    EIGHT   OF   WHICH    ARE   IN   COLORS. 

"it  is  certainly  lefiesiiing  that  a  man  of  the  experience  and  ability  of  the  author 
of  tliis  volume  has  culled  from  this  mass  of  literature  the  essentials,  and  given  us  in  a 
well-planned  volume  the  gi>t  of  the  entire  subject. 

"  The  book  is  systematically  arranged,  and  each  subject  is  taken  up  and  dealt  with 
in  a  way  tliat  makes  it  easily  accessible  to  the  busy  practitioner.  The  style  is  explicit 
and  never  verbose,  wiiich,  with  the  fine  vein  of  humor  running  through  it,  makes  it 
very  enjoyable  reading."' — Nortlrui'sleni  Lancet. 

"Gonorrhea  is  gone  into  more  extensively  than  in  any  other  work." — Denver 
Medical  Times. 

"  As  a  text-book  on  Genito-Urinary  Surgery  it  stands  at  the  head  of  the  publica- 
tions on  the  subject  in  the  Lnglish  language.  Our  readers  wishing  an  up-to-date  work 
on  the  subject  can  not  do  better  than  to  buy  this  latest  and  newest  work." — Medical 
Century. 

"The  book  is  well  illustrated,  well  printed,  well  arranged,  and  will  be  more 
popular  tlian  its  predecessors." — Chicago  Medical  Recorder. 

"The  chapters  on  the  affections  of  the  posterior  urethra,  prostate  and  seminal 
vesicles  are  especially  good,  and  many  'pointers'  are  found  in  the  chapter  on  the 
'Treatment  of  Urethral  Inflammation  and  their  Immediate  Complications.'  " — Canada 
Medical  Record. 

"This  is  a  good  book  on  an  important  subject.  Within  the  compass  of  800  pages 
it  gives  a  comprehensive  treatment  of  the  various  diseases  of  this  special  branch  of 
surgery,  and,  while  not  discarding  the  good  of  the  older  work,  it  embraces  all  that  is 
new  in  this  field."— yoitr/u?/  of  Medicine  and  Science. 

"  This  is  so  well  written  as  to  be  exhaustive  in  character,  and  needs  little  or  no 
comment  from  the  reviewer  further  than  to  mention  its  completeness  in  every  par- 
ticular."— Cincinnati  Lancet-Clinic. 

D  .     A  P  P  L  E  T  O  N     AND     COMPANY,     N  E  ^\'    Y  O  R  K . 


INTRODUCTION 

TO    THE    STUDY    OF 

MEDICINE 

By    G.    H.    ROGER 

PROFESSOR    EXTRAORDINARY    IN    THE    FACULTY    OF    MEDICINE    OF    PARIS 

MEMBER    OF    THE    BIOLOGICAL    SOCIETY 

PHYSICIAN    TO    THE     HOSPITAL    OF    PORTE-d' AUBERVILLIERS 

AUTHORIZED    TRANSLATIONS    BY 
M.  S.  GABRIEL,  M.  D. 

WITH  ADDITIONS  BY  THE  AUTHOR 
8vo.      Cloth,  $5.00 

"  Such  a  work,  well  conned,  provides  bepfinners  in  medicine  with  a  sure  and  wide  founda- 
tion of  systematic  science  on  which  to  base  all  their  future  acquirements.  Dr.  Roger's  unique 
volume  is  to  be  heartily  commended,  not  only  to  would-be  physicians  but  also  to  that  large 
class  of  post-graduates  who  do  not  cease  to  be  students  because  they  have  left  college,  and 
would  like  to  know  the  reasons  and  relations  of  things." — Medical  7 imes,  Denver,  Col. 

"The  work  throughout  shows  an  essentially  logical  method  of  treatment,  and  covers  a 
very  wide  subject  in  a  manner  which  amply  demonstrates  the  author's  extensive  acquaintance 
with  medical  thought  and  medical  literature.  The  book  can  be  recommended  not  only  to 
students,  but  also  to  practitioners  in  medicine,  as  giving  a  wide  and  philosophical  view  of 
medicine  and  iis  tendencies  at  the  present  day." — Albany  Medical  Annals,  Albany,  A^.  Y. 

"  As  a  resiimS  of  recent  medical  advancement  we  may  expect  this  volume  to  occupy  a 
unique  place.  It  is  something  of  a  novelty  to  turn  the  pages  of  a  medical  work  which  will 
be  most  valuable  to  the  profession  as  a  whole,  not  to  the  specialist  or  individual  student  alone. 
It  is,  however,  well  suited  to  use  as  a  text-book,  and  will  put  students  in  touch  with  rapdicine 
as  an  all-embracing  science.  But  to  those  of  the  profess'on— and  there  are  many — who  lack 
opportunity  to  thoroughly  acqiaint  themselves  with  tlie  rapid  strides  which  are  being  made  in 
knowled_:e  of  the  causation  of  disease,  lesions  and  reactions  of  the  organism  which  are  dis- 
cussed under  pathol  igical  anatomy  and  semeiologj',  the  work  will  serve  as  a  substitute  for 
lectures  and  laboratory  experience.  Some  of  the  principal  chapters  deal  with  the  mechanical, 
physical,  chemical,  and  animate  agencifis  of  disease,  the  general  etiology  and  pathogenesis  of 
the  infectious  diseases,  nervous  reactions,  disturbances  of  nutrition,  heredity,  inflammation, 
septicemia  and  pyemia,  tumors,  Cf-Uular  degenerations,  examination  of  the  sick,  clinical  appli- 
cation of  scientific  y)rocedures,  diagnosis  and  prognosis,  therapeutics,  etc.  An  immense 
amount  of  work  is  evidenced  by  the  text,  and  much  careful  and  scholarly  research.  A  book 
of  this  kind  is  needed,  and  will  be  particularly  appreciated  by  those  who,  without  undervaluing 
the  importance  of  laboratory  investigations,  still  think  clinical  methods  and  the  simpler  means 
of  reaching  a  diagnosis  and  prognosis  should  not  be  forgotten  or  slighted." — New  England 
Medical  Gazette,  Boston,  Mass. 

D.  APPLETON    AND   COMPANY,   NEW  YORK 


THE  DISEASES  OF  INFANCY 
AND  CHILDHOOD. 

By  L.   EMMET    HOLT,   A.  M.,   M.  D., 

Professor  of  Diseases  of  Children  in  tiie  College  of  Physicians  and  Surgeons  (Columbia 

University)  ;  Consulting  F^hysician  to  the  New  York  infant  Asylum, 

and  to  the  Hospital  for  Ruptured  and  Crippled. 

SECOND  EDITION,   REVISED  AND  ENLARGED.  WITH  TWO 

HUNDRED  AND  TWENTY-FIVE   ILLUSTRATIONS, 

INCLUDING   NINE    COLORED    PLATES. 

Cloth,  $6.00 ;   half  leather,  §b.=;o. 

Sold  only  by  Subscription. 

"Throughout  the  work  the  evidence  of  careful  revision  is  everywhere  apparent, 
and  the  volume  represents  essentially  the  best  exposition  of  the  latter-day  pediatric 
teaching." — Cleveland  Medical  Journal. 

"  This  second  edition  is  even  better  than  the  first,  and  more  than  retains  the  high 
position  taken  by  its  predecessor.  No  one  interested  in  the  diseases  of  childhood  can 
afford  to  be  witliout  it." — Boston  Medical  and  Surgical  Journal. 

"No  radical  departure  from  the  previous  edition  has  been  instituted  in  this  the 
second  edition.  Tlie  material  has,  however,  undergone  a  thorough  revision,  with  the 
addition  of  new  and  thoroughly  tried  methods  of  diagnosis  and  treatment  which  have 
been  accepted  since  the  appearance  of  the  previous  edition.  The  most  noteworthy 
change  has  been  in  the  cliapter  on  Milk  and  Infant  feeding.  This  section  has  been 
completely  rewritten,  with  tlie  addition  of  much  new  and  valuable  material  in  accord 
with  the  great  advance  made  in  this  important  branch  of  pediatrics.  Old  illustrations 
have  been  replaced  by  newer  and  better  ones  New  charts  and  diagrams,  with  twenty- 
one  additional  illustrations,  enhance  the  value  of  an  already  accepted  standard  work." 
—  Yale  Medical  Journal. 

"  Holt  is  recognized  as  one  of  the  foremost  authorities  on  pediatrics  of  America, 
and  therefore  of  the  world.  He  has  made  a  very  extensive  first-hand  study  of  the  care 
ot  children  and  their  diseases,  and  so  writes  from  a  mind  replete  with  the  clinical 
pictures  of  suffering  childhood.  The  work  is  complete  t'rom  every  practical  standpoint, 
and  the  text  embraces  1161  octavo  pages.  The  student  or  practitioner  who  has  Holt 
at  hand  need  hardly  ever  be  at  a  loss  for  a  reliable  line  of  treatment  in  his  pediatric 
practise."— "Denver  Medical  Times. 

"  The  changes  within  the  past  five  years  have  not  been  very  extensive,  yet  the 
many  new  facts  that  have  come  out  in  the  rapidly  advancing  science  of  pediatrics  have 
here  all  received  their  sliare  of  careful  and  judiciaf  treatment. 

"  The  extremely  practical  question  of  infant  feedins:,  as  is  well  known,  has  been  a 
subject  of  special  study  by  the  author,  and  one  in  which  medical  advances  have  been 
made  very  largely  identified  with  his  name.  It  is  a  pleasure  to  find  the  subject  han- 
dled in  a  text-book  in  a  comprehensive  and  yet  common-sense  manner." — Neu-  York 
Medical  News. 

D  .    A  P  P  L  E  T  O  N     AND     COMPANY,    X  E  W'    YORK. 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrajigement  with ' 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE   BORROWED 

DATE  DUE 

C28  (449)M50 

RC341                      P31 

1904 

Pearce 

A  tract 
disease 

ical  treatise  on  nervous 

p. 

1 

